Interventions for Deliberately Altering Blood Pressure in Acute Stroke | Journal Scan
What is the evidence for clinical effectiveness of altering blood pressure (BP) in patients with acute stroke?
The investigators used the available studies via Cochrane, MEDLINE (1966 to May 2014), EMBASE (1974 to May 2014), Science Citation Index (1981 to May 2014), and the Stroke Trials Registry (http://www.strokecenter.org/trials/). Published and unpublished randomized controlled trials evaluating single or multiple agents, regardless of drug dosage or route of treatment, aimed at altering BP within 1 week of acute ischemic or hemorrhagic stroke were eligible. Also included were trials assessing effects of continuing or stopping pre-existing antihypertensive treatment. Using an a priori protocol, two reviewers independently applied the inclusion criteria, assessed trial quality, and extracted data. Outcomes were assessed according to drug class, stroke type, stroke location, and by time to treatment. The primary outcome was combined death or dependency/disability at end of the trial (≥1 month after stroke).
A total of 26 trials were included, which involved 17,011 patients. Twenty-four assessed BP lowering in 15,432 patients; two trials (involving 2,860 patients) evaluated whether to continue or stop prestroke antihypertensive treatment. BP lowering did not reduce death or dependency (odds ratio, 0.98; 95% CI, 0.92-1.05) and did not differ by drug class or stroke type. Treatment within 6 hours, but not beyond, was associated with reduced death or dependency (odds ratio, 0.86; 95% CI, 0.76-0.99). Although death or dependency did not differ between patients who continued prestroke antihypertensive treatment versus those who stopped it temporarily (worse outcome with continuing treatment, odds ratio, 1.06; 95% CI, 0.91-1.24), disability scores at the end of the trial were worse in patients randomized to continue treatment. Insufficient data were available to assess the effect of BP elevation.
BP lowering during the acute phase of stroke did not improve functional outcome. However, early initiation of treatment may be beneficial, and additional studies are required to test this question. Continuing prestroke antihypertensive drugs immediately after acute stroke may be harmful.
The issue is critically important and needs a study that is adequately powered and designed. In this analysis, the authors combined results in studies of acute ischemic and acute hemorrhagic strokes, which makes little sense. The largest study conducted in acute ischemic stroke was CUTIS, a single-blind study in 4,071 Chinese patients with a nonthrombolysed ischemic stroke who were randomized to treatment targeting BP lowering of 10-25% in 24 hours and <140/90 mm Hg within 7 days, or to discontinue all antihypertensive medication. The outcome did not differ between treatment groups at 14 days or hospital discharge or at 3-month post-treatment follow-up. In the largest study in acute hemorrhagic stroke (INTERACT-2), of 2,794 patients with spontaneous intracranial hemorrhage, the relative risk for poor outcome was 0.94, p = 0.063, in the intensive BP-lowering group (target systolic BP ≤140 mm Hg) compared with the control guideline group (sBP ≤180 mm Hg). No differences in mortality and major safety events, including neurological worsening, were observed. The evidence does not support an aggressive approach to lowering the BP in either acute hemorrhagic or acute ischemic strokes.
Keywords: Antihypertensive Agents, Blood Pressure, Hypotension, Intracranial Hemorrhages, MEDLINE, Registries, Stroke, Time-to-Treatment, Treatment Outcome
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