Should We Lower Blood Pressure in Acute Ischemic Stroke?

December 10, 2013

Should We Lower Blood Pressure in Acute Ischemic Stroke?

  1. Allan S. Brett, MD

In a randomized trial, outcomes were neither better nor worse with early antihypertensive therapy.

  1. Allan S. Brett, MD

A 2013 guideline from the American Stroke Association recommends that we avoid antihypertensive drug therapy during the first 24 hours after onset of acute ischemic stroke unless systolic or diastolic blood pressure (BP) exceeds 220 mm Hg or 120 mm Hg, respectively. (The threshold is 185/110 mm Hg for patients receiving thrombolytic therapy; Stroke 2013; 44:870) The concern is that early BP lowering might worsen stroke outcomes. However, no large randomized trials have tested this theory, until now.

Researchers in China randomized 4700 patients with acute ischemic stroke to receive antihypertensive therapy (target BP, 140/90 mm Hg) or no antihypertensive therapy, initiated within 24 hours. Patients were excluded if BP was >220/120 mm Hg, thrombolytic therapy was given, or compelling reasons existed to lower BP (e.g., severe heart failure). Treatment algorithms included angiotensin-converting–enzyme inhibitors, calcium-channel blockers, and diuretics. At entry, mean BP was 166/97 mm Hg.

At 24 hours, mean systolic BP had fallen by 22 mm Hg in the treatment group and by 13 mm Hg in the control group — a significant difference. At 1 week, systolic BP remained separated by about 10 mm Hg, and two thirds of intervention patients (vs. one third of controls) had systolic BP lower than 140 mm Hg. However, the outcome of death or major disability was identical in the two groups at 14 days (34%) and 3 months (25%).


Because BP-lowering early in acute ischemic stroke did not improve or worsen outcomes in this important study, the authors conclude that “the decision to lower blood pressure … should be based on individual clinical judgment.” Although that conclusion is reasonable, the individual clinical factors that might tip the balance toward antihypertensive therapy remain unclear.

Editor Disclosures at Time of Publication

  • Disclosures for Allan S. Brett, MD at time of publication Nothing to disclose


Reader Comments (4)

Eamonn Doyle Other, Ireland

My father is 83 yrs old his doctor took him off his blood pressure tabs 6_8was ago when I heard that I said he will have a stroke + he did 3+ half was ago he also had diabetes controlled by diet he had an ischaemic stroke. I put it to his doctor that he shouldn't have taken him off his blood pressure tablets he replied that had nothing to do with his STROKE. I'm not happy with his reply as he dismissed my question very quickly . He had afew tips over the last few yrs too. I just feel somethings not right.all views appreciated. Regards Eamonn

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

Short-acting calcium-channel blocker nifedipine should be avoided in hypertensive urgency. Dropping the blood pressure too quickly, and too much, can worsen target end-organ damage. The stroke risk associated with short-acting nifedipine was particulary elevated in patients with atrial fibrillation, heart failure, ischemic heart disease.

steven moser Other, Pharmacology/Pharmacy

stroke and permissive HTN

David Keller, M.D., M.S. Physician, Internal Medicine, Disabled

Nimodipine reduces cerebral ischemia in cases of subarachnoid hemorrhage, independent of its anti-hypertensive effect, due to its ability as a calcium-channel blocker to reduce the vasospasm of brain arterioles exposed to blood in the CSF. Did this study control for the number of patients in each arm who received nimodipine, and similar calcium channel blockers which cross the blood brain barrier?

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