This patient should receive no pharmacologic treatment. He has an ischemic stroke in the pons, which is commonly caused by hypertensive changes in penetrator vessels originating from the basilar artery. He is not a candidate for intravenous thrombolysis because 18 hours have passed since he was known to be well. He has an elevated blood pressure but no evidence of end-organ damage. Treatment guidelines advise treatment of hypertension in the setting of acute ischemic stroke only if blood pressure is greater than 220/120 mm Hg or evidence of other end-organ damage exists. The rationale for these guidelines is to prevent neurologic worsening from expansion of the cerebral infarct; in recent clinical trials, acute lowering of blood pressure with candesartan within 36 hours of stroke was associated with neurologic worsening. When appropriate, antihypertensive medications are commonly started close to the day of discharge home or to a rehabilitation facility.

Neither oral captopril nor oral metoprolol is appropriate for this patient, who does not require immediate treatment of hypertension. Additionally, he should not be given any oral medication until a dysphagia evaluation documents the ability to swallow.

Sublingual nitroglycerin is also inappropriate because the patient does not require therapy to lower blood pressure at this time.