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Start Antihypertensive Therapy Early for Acute Stroke

Summary and Comment |
December 9, 2013

Start Antihypertensive Therapy Early for Acute Stroke

  1. Hooman Kamel, MD

A large randomized trial showed no difference in functional outcomes but better long-term blood pressure control in patients started on antihypertensive therapy during stroke hospitalization.

  1. Hooman Kamel, MD

Clinical trials have had inconclusive findings regarding the management of hypertension during hospitalization for acute ischemic stroke. To fill this knowledge gap, researchers conducted the China Antihypertensive Trial in Acute Ischemic Stroke (CATIS), a large, multicenter, randomized clinical trial. Investigators enrolled 4071 patients within 48 hours after onset of ischemic stroke (78% thrombotic; median NIH Stroke Scale score, 4.0). The patients had systolic blood pressure (SBP) between 140 and 220 mm Hg at enrollment; those with widely accepted indications for acute antihypertensive treatment (thrombolytic treatment, SBP >220 mm Hg, or hypertensive end-organ injury) were excluded. Eligible patients were randomized to permissive hypertension until hospital discharge, including discontinuation of any previously prescribed antihypertensive drugs (control group), or to a strategy of reducing SBP by 10% to 25% during the first 24 hours to a goal of <140/90 mm Hg by day 7 and until hospital discharge (treatment group). Both groups received usual antihypertensive therapy after discharge.

Compared with the control group, the treatment group had an average 9.1 mm Hg lower SBP level at 24 hours and a 9.2 mm Hg lower level at 7 days. Rates of the primary outcome (death or modified Rankin Scale score ≥3) did not differ significantly between groups at hospital discharge or 3 months. At 3 months, the treatment group (85% taking antihypertensive medication) had significantly lower SBP (by 2.9 mm Hg) than the control group (75% taking antihypertensive medication) and a nonsignificantly lower rate of recurrent stroke (1.4% versus 2.2%).

Comment

These findings may not apply to patients with very large or cardioembolic strokes. Nevertheless, the results fill some crucial knowledge gaps in current acute stroke treatment guidelines. Given the importance of long-term blood pressure control for preventing recurrent stroke, it appears reasonable to gently start or reintroduce antihypertensive therapy in most neurologically stable patients 24 hours after stroke.

  • Disclosures for Hooman Kamel, MD at time of publication Consultant / Advisory board Genentech Grant / research support American Heart Association

Citation(s):

Reader Comments (3)

Dr. V Kantariya MD Physician, Family Medicine/General Practice

Acute antihypertensive therapy early for acute stroke is good for the Brain. Lower is Better for the brain, kidney, and retina But Not for the Heart. "Would your patient rather die of a heart attack or be blind, paralyzed, and on dialysis? QUESTION! CHOOSING WISELY!

MUHAMMAD IDREES Fellow-In-Training, Internal Medicine

what are the guidelines for BP control and type of iv fluid in intracerebral hemorrage. there is lot of conflict between consultants on this matter. few stop all oral treatment for 2 days and gine iv normal saline. control BP with captopril only when it is above 180/110. while others have different opinions. i want to be clear about
1. if a known hypertensive comes with intracerebral haemorrage and his BP is more then 180 systolic then what to do
2. if a patient who has no history of hypertension before with same problem , what then?
3. what should be the iv fluid of choice in a hypertensive patient with intracerebral hemorrage haemorrage
thanks

MD Physician, Internal Medicine, najran universty saudi arabia

many studies had being conducted about this two seperate intaty; controloing the blood pressure over long term to prevent the stroke and give antihypertensive flowing stroke immadiatly if the patient is known hypertensive and present with highBP s>220. stile given anihypertensive for thoes patient not acceptable specially in the first 24 h and this well disturbe the crebral autoregulation and can lead to reflex cerebal vasospam.and ofcoures it differant if it is ischmeia or hemorrhage.
i think this study well open the door again for the question that not been solved yet and this very good in guide us to fine what best we can offere for the patients ..thank you very much

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