BP therapy didn’t boost survival in ischemic stroke

DALLAS – Immediate blood pressure reduction in hypertensive acute ischemic stroke patients did not reduce death and disability after 14 days, but the strategy was safe and did not worsen patient’s 14-day outcomes, a randomized controlled study has shown.

The findings suggest that, among patients with relatively mild acute ischemic strokes and a systolic blood pressure of 140-219 mm Hg, "the decision to lower blood pressure with antihypertensive treatment should be based on individual clinical judgment," Dr. Jiang He said at the American Heart Association scientific sessions.

Elevated blood pressure immediately following an ischemic stroke poses a risk of hemorrhagic conversion or cerebral edema, but an elevated blood pressure also might be protective by forcing more blood into the penumbra around the stroke site. Blood pressure reduction measures are not appropriate for patients treated by reperfusion, but they are considered necessary for patients with "markedly elevated" blood pressure, generally defined as a systolic pressure of 220 mm Hg or higher, he said.

U.S. guidelines on stroke management published earlier this year noted that the data to guide recommendations for treating less severe arterial hypertension, in the range studied in this trial, are "inconclusive or conflicting," and that "the benefit of treating arterial hypertension in the setting of acute ischemic stroke is not well established" (Stroke 2013;44:870-947). Some U.S. clinicians, however, take steps to reduce moderately elevated blood pressure in acute ischemic stroke patients, especially when systolic pressures are at or close to 200 mm Hg.

Based on the new findings, Dr. Sila proposed in her formal comments a strategy for managing patients with mild ischemic strokes who do not undergo reperfusion treatment and have a systolic pressure of 140-219 mm Hg more than 15 hours after their stroke onset and no major-vessel stenosis or occlusion. She suggested that a "reasonable" goal was to lower blood pressure by 10%-15% over the first 24 hours of treatment, with a goal blood pressure of less than 140/90 mm Hg within the next 7 days.

The China Antihypertensive Trial in Acute Ischemic Stroke (CATIS) randomized 4,071 patients aged 22 years or older with a confirmed ischemic stroke who did not undergo reperfusion treatment at 26 hospitals in China. Their average age was 62 years, they were seen an average of 15 hours after their stroke onset, and they had a median National Institutes of Health Stroke Scale score of 4.

The 2,038 patients randomized to blood pressure reduction received an intravenous angiotensin-converting enzyme inhibitor, enalapril, as their first-line treatment, followed by a calcium channel blocker as second-line treatment and a diuretic as a third-line agent. The objective was to reduce systolic pressure by 10%-25% within the first 24 hours, with a goal blood pressure of less than 140/90 mm Hg after 7 days.

The treatments were effective, resulting in an average 13% reduction in blood pressure in treated patients after 24 hours (an average drop of 22 mm Hg), and an average systolic pressure of 137 mm Hg after 7 days. The control patients had an average 7% reduction in their systolic pressure, an average reduction of 13 mm Hg after 24 hours, and an average systolic pressure of 147 mm Hg after 7 days. All of the differences were significant.

The study’s primary endpoint was the rate of death or major disability (a modified Rankin score of 3 or higher) at 14 days or at the time of hospital discharge. This endpoint occurred in 34% of patients in both the intervention and control arms, reported Dr. He, professor of epidemiology at Tulane University in New Orleans. After 14 days or at discharge, the average modified Rankin score was 2 for patients in both treatment arms.

The report by Dr. He and his associates was published online in JAMA (2013 Nov. 17 [doi:10.1001/jama.2013.282543]) concurrently with his presentation.

Dr. He and Dr. Sila said that they had no disclosures.

[email protected]

On Twitter @mitchelzoler

DALLAS – Immediate blood pressure reduction in hypertensive acute ischemic stroke patients did not reduce death and disability after 14 days, but the strategy was safe and did not worsen patient’s 14-day outcomes, a randomized controlled study has shown.

The findings suggest that, among patients with relatively mild acute ischemic strokes and a systolic blood pressure of 140-219 mm Hg, "the decision to lower blood pressure with antihypertensive treatment should be based on individual clinical judgment," Dr. Jiang He said at the American Heart Association scientific sessions.

Elevated blood pressure immediately following an ischemic stroke poses a risk of hemorrhagic conversion or cerebral edema, but an elevated blood pressure also might be protective by forcing more blood into the penumbra around the stroke site. Blood pressure reduction measures are not appropriate for patients treated by reperfusion, but they are considered necessary for patients with "markedly elevated" blood pressure, generally defined as a systolic pressure of 220 mm Hg or higher, he said.

U.S. guidelines on stroke management published earlier this year noted that the data to guide recommendations for treating less severe arterial hypertension, in the range studied in this trial, are "inconclusive or conflicting," and that "the benefit of treating arterial hypertension in the setting of acute ischemic stroke is not well established" (Stroke 2013;44:870-947). Some U.S. clinicians, however, take steps to reduce moderately elevated blood pressure in acute ischemic stroke patients, especially when systolic pressures are at or close to 200 mm Hg.

Based on the new findings, Dr. Sila proposed in her formal comments a strategy for managing patients with mild ischemic strokes who do not undergo reperfusion treatment and have a systolic pressure of 140-219 mm Hg more than 15 hours after their stroke onset and no major-vessel stenosis or occlusion. She suggested that a "reasonable" goal was to lower blood pressure by 10%-15% over the first 24 hours of treatment, with a goal blood pressure of less than 140/90 mm Hg within the next 7 days.

The China Antihypertensive Trial in Acute Ischemic Stroke (CATIS) randomized 4,071 patients aged 22 years or older with a confirmed ischemic stroke who did not undergo reperfusion treatment at 26 hospitals in China. Their average age was 62 years, they were seen an average of 15 hours after their stroke onset, and they had a median National Institutes of Health Stroke Scale score of 4.

The 2,038 patients randomized to blood pressure reduction received an intravenous angiotensin-converting enzyme inhibitor, enalapril, as their first-line treatment, followed by a calcium channel blocker as second-line treatment and a diuretic as a third-line agent. The objective was to reduce systolic pressure by 10%-25% within the first 24 hours, with a goal blood pressure of less than 140/90 mm Hg after 7 days.

The treatments were effective, resulting in an average 13% reduction in blood pressure in treated patients after 24 hours (an average drop of 22 mm Hg), and an average systolic pressure of 137 mm Hg after 7 days. The control patients had an average 7% reduction in their systolic pressure, an average reduction of 13 mm Hg after 24 hours, and an average systolic pressure of 147 mm Hg after 7 days. All of the differences were significant.

The study’s primary endpoint was the rate of death or major disability (a modified Rankin score of 3 or higher) at 14 days or at the time of hospital discharge. This endpoint occurred in 34% of patients in both the intervention and control arms, reported Dr. He, professor of epidemiology at Tulane University in New Orleans. After 14 days or at discharge, the average modified Rankin score was 2 for patients in both treatment arms.

The report by Dr. He and his associates was published online in JAMA (2013 Nov. 17 [doi:10.1001/jama.2013.282543]) concurrently with his presentation.

Dr. He and Dr. Sila said that they had no disclosures.

[email protected]

On Twitter @mitchelzoler

DALLAS – Immediate blood pressure reduction in hypertensive acute ischemic stroke patients did not reduce death and disability after 14 days, but the strategy was safe and did not worsen patient’s 14-day outcomes, a randomized controlled study has shown.

The findings suggest that, among patients with relatively mild acute ischemic strokes and a systolic blood pressure of 140-219 mm Hg, "the decision to lower blood pressure with antihypertensive treatment should be based on individual clinical judgment," Dr. Jiang He said at the American Heart Association scientific sessions.

Elevated blood pressure immediately following an ischemic stroke poses a risk of hemorrhagic conversion or cerebral edema, but an elevated blood pressure also might be protective by forcing more blood into the penumbra around the stroke site. Blood pressure reduction measures are not appropriate for patients treated by reperfusion, but they are considered necessary for patients with "markedly elevated" blood pressure, generally defined as a systolic pressure of 220 mm Hg or higher, he said.

U.S. guidelines on stroke management published earlier this year noted that the data to guide recommendations for treating less severe arterial hypertension, in the range studied in this trial, are "inconclusive or conflicting," and that "the benefit of treating arterial hypertension in the setting of acute ischemic stroke is not well established" (Stroke 2013;44:870-947). Some U.S. clinicians, however, take steps to reduce moderately elevated blood pressure in acute ischemic stroke patients, especially when systolic pressures are at or close to 200 mm Hg.

Based on the new findings, Dr. Sila proposed in her formal comments a strategy for managing patients with mild ischemic strokes who do not undergo reperfusion treatment and have a systolic pressure of 140-219 mm Hg more than 15 hours after their stroke onset and no major-vessel stenosis or occlusion. She suggested that a "reasonable" goal was to lower blood pressure by 10%-15% over the first 24 hours of treatment, with a goal blood pressure of less than 140/90 mm Hg within the next 7 days.

The China Antihypertensive Trial in Acute Ischemic Stroke (CATIS) randomized 4,071 patients aged 22 years or older with a confirmed ischemic stroke who did not undergo reperfusion treatment at 26 hospitals in China. Their average age was 62 years, they were seen an average of 15 hours after their stroke onset, and they had a median National Institutes of Health Stroke Scale score of 4.

The 2,038 patients randomized to blood pressure reduction received an intravenous angiotensin-converting enzyme inhibitor, enalapril, as their first-line treatment, followed by a calcium channel blocker as second-line treatment and a diuretic as a third-line agent. The objective was to reduce systolic pressure by 10%-25% within the first 24 hours, with a goal blood pressure of less than 140/90 mm Hg after 7 days.

The treatments were effective, resulting in an average 13% reduction in blood pressure in treated patients after 24 hours (an average drop of 22 mm Hg), and an average systolic pressure of 137 mm Hg after 7 days. The control patients had an average 7% reduction in their systolic pressure, an average reduction of 13 mm Hg after 24 hours, and an average systolic pressure of 147 mm Hg after 7 days. All of the differences were significant.

The study’s primary endpoint was the rate of death or major disability (a modified Rankin score of 3 or higher) at 14 days or at the time of hospital discharge. This endpoint occurred in 34% of patients in both the intervention and control arms, reported Dr. He, professor of epidemiology at Tulane University in New Orleans. After 14 days or at discharge, the average modified Rankin score was 2 for patients in both treatment arms.

The report by Dr. He and his associates was published online in JAMA (2013 Nov. 17 [doi:10.1001/jama.2013.282543]) concurrently with his presentation.

Dr. He and Dr. Sila said that they had no disclosures.

[email protected]

On Twitter @mitchelzoler