Blood Pressure Management in Acute Stroke
2011; Lippincott Williams & Wilkins; Volume: 42; Issue: 10 Linguagem: Inglês
10.1161/strokeaha.111.619346
ISSN1524-4628
AutoresUrs Fischer, Peter M. Rothwell,
Tópico(s)Traumatic Brain Injury and Neurovascular Disturbances
ResumoHomeStrokeVol. 42, No. 10Blood Pressure Management in Acute Stroke Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBBlood Pressure Management in Acute StrokeDoes the Scandinavian Candesartan Acute Stroke Trial (SCAST) Resolve All of the Unanswered Questions? Urs Fischer, MD, MSc and Peter M. Rothwell, PhD, FMedSci Urs FischerUrs Fischer From the Department of Neurology (U.F.), University Hospital Bern and University of Bern, Bern, Switzerland; and the Stroke Prevention Research Unit (P.M.R.), Nuffield Department of Clinical Neuroscience, University of Oxford, Oxford, UK. and Peter M. RothwellPeter M. Rothwell From the Department of Neurology (U.F.), University Hospital Bern and University of Bern, Bern, Switzerland; and the Stroke Prevention Research Unit (P.M.R.), Nuffield Department of Clinical Neuroscience, University of Oxford, Oxford, UK. Originally published18 Aug 2011https://doi.org/10.1161/STROKEAHA.111.619346Stroke. 2011;42:2995–2998Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2011: Previous Version 1 IntroductionWhether raised blood pressure in patients with acute stroke should be treated is one of the major unresolved issues in acute stroke management, due mainly to a paucity of reliable data from sufficiently powered randomized controlled trials. However, the Scandinavian Candesartan Acute Stroke Trial (SCAST), recently published in The Lancet, adds important new information about the risks and benefits of treatment of poststroke hypertension.1 Else Sandset and colleagues assessed whether careful blood pressure-lowering treatment with candesartan is beneficial in a wide range of patients with acute ischemic and hemorrhagic stroke and raised blood pressure.Rationale for Blood Pressure-Lowering in Acute StrokeBlood pressure is increased in up to 75% to 80% of patients with acute stroke and usually decreases spontaneously over the next few days.2–4 The cause of this transient rise in blood pressure (ie, poststroke hypertension) is unknown. A specific physiological reaction to the stroke itself is often postulated, possibly due to disturbed cerebral autoregulation,5 damage or compression of brain regions that regulate the autonomic nervous system,6 or neuroendocrine factors.7,8 However, nonstroke-specific mechanisms such as headache,6 urine retention,6 infection,9 and psychological stress of admission to hospital10,11 have also been postulated.Data from observational studies have consistently shown that raised blood pressure after stroke is associated with poor short- and long-term outcomes.12–14 In patients with acute ischemic stroke, raised blood pressure is potentially harmful because it increases the risk of cerebral edema and hemorrhagic transformation in the freshly infarcted brain tissue.6 In patients with hemorrhagic stroke, high blood pressure increases the risk of hematoma expansion, growth of the perihematomal edema, and early rebleeding into the brain.15 However, optimum management of poststroke hypertension remains controversial, particularly in ischemic stroke, in which there are concerns that lowering blood pressure reduces blood flow from collateral vessels to the ischemic penumbra and increases the size of the brain infarction or perihematomal ischemia.16 A Cochrane review of 12 randomized trials of blood pressure lowering in acute stroke in a total of 1153 patients within 1 week of acute ischemic or hemorrhagic stroke concluded that there is insufficient evidence to reliably assess effects on functional outcome or death.17 Therefore, the current guidelines do not recommend blood pressure-lowering in patients with acute stroke unless levels are extremely high or thrombolysis is being considered.18,19The Acute Candesartan Cilexetil Therapy in Stroke Survivors (ACCESS) study randomized 342 patients with high blood pressure to candesartan versus placebo during the first week after stroke and reported a reduced risk of vascular events and deaths during the next 12 months (OR, 0.48; 95% CI, 0.25 to 0.90). However, there was no effect on the primary end point of functional outcome and most of the vascular events that were prevented were transient ischemic attacks.20 Nevertheless, these results encouraged the investigators of the SCAST trial to assess the effect on moderate blood pressure-lowering drugs on outcome in a larger randomized controlled trial.Results of the SCAST TrialSCAST was a large, multicenter, randomized placebo-controlled, double-blind trial that enrolled patients with acute ischemic (85%) or hemorrhagic (14%) stroke and systolic blood pressure of ≥140 mm Hg. A total of 2029 patients were randomly assigned within 30 hours of symptom onset (average 18 hours) to either candesartan cilexetil (1017 patients) or placebo (1012 patients) for 7 days with doses increasing from 4 mg on Day 1 to 16 mg on Days 3 to 7. Demographic and clinical characteristics at baseline were well balanced between treatment groups. Mean blood pressure was 171/90 mm Hg on admission but was significantly lower in patients allocated to candesartan than in those on placebo (P≤0.001) during the 7-day treatment period with a mean difference in systolic blood pressure on Day 7 of 5 mm Hg (95% CI, 3 to 7; P 185 mm Hg.18 Results from SCAST should probably not stop clinicians from lowering blood pressure in candidates for thrombolysis. Recanalization is the most important modifiable predictor of outcome in patients with acute stroke,34 and observational data suggest that blood pressure-lowering before intravenous tissue plasminogen activator therapy, even using aggressive measures, may not be associated with a poor outcome.35 However, further trials are required to address this question more reliably. In the meantime, thrombolysis should probably not be withheld due to high blood pressure, if it can be lowered to 185 mm Hg, because the potential damage of a moderate blood pressure reduction is probably smaller than to withhold thrombolysis.In conclusion, the results of the SCAST trial indicate that there does not seem to be any benefit from starting oral blood pressure-lowering therapy with candesartan within the first week of stroke. Whether particular subgroups of patients with stroke might benefit from early treatment and whether other drugs are effective has yet to be determined.Implications for Future ResearchGiven the many unanswered questions regarding antihypertensive therapy despite SCAST and at the same time as awaiting the results of the ongoing randomized trials (INTERACT 2, Efficacy of Nitric Oxide in Stroke [ENOS]),22,36 more research is required on the mechanisms of poststroke hypertension. In an ideal world, future randomized controlled trials assessing the impact of blood pressure-lowering on outcome in patients with acute stroke would take into consideration stroke severity, stroke etiology, premorbid blood pressure levels, and findings of imaging such as the presence of a penumbra and intra- and extracranial stenoses, although statistical power will always be limited in some subgroups. Whether different classes of antihypertensives drugs should be investigated is also open to question.DisclosuresP.M.R. is in receipt of a National Institute for Health Research Senior Investigator Award and a Wellcome Trust Senior Investigator Award.FootnotesCorrespondence to Urs Fischer, MD, Department of Neurology, University of Bern, Inselspital, Freiburgstrasse 4, 3010 Bern, Switzerland. E-mail urs.[email protected]chReferences1. Sandset EC, Bath PMW, Boysen G, Jatuzis D, Korv J, Lüders S , et al; on behalf of the SCAST Study Group. The angiotensin-receptor blocker candesartan for treatment of acute stroke (SCAST): a randomised, placebo-controlled, double-blind trial. Lancet. 2011; 377:741–750.CrossrefMedlineGoogle Scholar2. Wallace JD, Levy LL. Blood pressure after stroke. JAMA. 1981; 246:2177–2180.CrossrefMedlineGoogle Scholar3. Britton M, Carlsson A, de Faire U. Blood pressure course in patients with acute stroke and matched controls. Stroke. 1986; 17:861–864.LinkGoogle Scholar4. Toyoda K, Okada Y, Fujimoto S, Hagiwara N, Nakachi K, Kitazono T, et al. Blood pressure changes during the initial week after different subtypes of ischemic stroke. Stroke. 2006; 37:2637–2639.LinkGoogle Scholar5. Olsen TS, Larsen B, Herning M, Skriver EB, Lassen NA. Blood flow and vascular reactivity in collaterally perfused brain tissue. Evidence of an ischaemic penumbra in patients with acute stroke. Stroke. 1983; 14:332–342.LinkGoogle Scholar6. Qureshi AI. Acute hypertensive response in patients with stroke: pathophysiology and management. Circulation. 2008; 118:176–187.LinkGoogle Scholar7. Olsson T, Marklund N, Gustafson Y, Nasman B. Abnormalities at different levels of the hypothalamic–pituitary–adrenocortical axis early after stroke. Stroke. 1992; 23:1573–1576.LinkGoogle Scholar8. Myers MG, Norris JW, Hachinski VC, Sole MJ. Plasma norepinephrine in stroke. Stroke. 1981; 12:200–203.LinkGoogle Scholar9. Chamorro A, Amaro S, Vargas M, Obach V, Cervera A, Gomez-Choco M, et al. Catecholamines, infection, and death in acute ischemic stroke. J Neurol Sci. 2007; 252:29–35.CrossrefMedlineGoogle Scholar10. Carlberg B, Asplund K, Hägg E. Factors influencing admission blood pressure levels in patients with acute stroke. Stroke. 1991; 22:527–530.LinkGoogle Scholar11. Carlberg B, Asplund K, Hägg E. High blood pressure in acute stroke. Is it white coat hypertension?J Intern Med. 1990; 228:291–292.MedlineGoogle Scholar12. Qureshi AI, Ezzeddine MA, Nasar A, Suri MF, Kirmani JF, Hussein HM, et al. Prevalence of elevated blood pressure in 563 704 adult patients with stroke presenting to the ED in the United States. Am J Emerg Med. 2007; 25:32–38.CrossrefMedlineGoogle Scholar13. Leonardi-Bee J, Bath PM, Phillips SJ, Sandercock PA. Blood pressure and clinical outcomes in the International Stroke Trial. Stroke. 2002; 33:1315–1320.LinkGoogle Scholar14. Willmot M, Leonardi-Bee J, Bath PM. High blood pressure in acute stroke and subsequent outcome: a systematic review. Hypertension. 2004; 43:18–24.LinkGoogle Scholar15. Qureshi AI, Mendelow AD, Hanley DF. Intracerebral haemorrhage. Lancet. 2009; 373:1632–1644.CrossrefMedlineGoogle Scholar16. Tikhonoff V, Zhang H, Richart T, Staessen JA. Blood pressure as a prognostic factor after acute stroke. Lancet Neurol. 2009; 8:938–948.CrossrefMedlineGoogle Scholar17. Greegange C, Bath PMW. Interventions for deliberately lowering blood pressure in acute stroke. Cochrane Database Syst Rev. 2008; 4:CD000039.CrossrefGoogle Scholar18. European Stroke Organisation (ESO) Executive Committee; ESO Writing Committee. Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis. 2008; 25:457–507.CrossrefMedlineGoogle Scholar19. Adams HP, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke. 2007; 38:1655–1771.LinkGoogle Scholar20. Schrader J, Lüders S, Kulschewski A, Berger J, Zidek W, Treib J , et al; on behalf of the ACCESS Study Group. The ACCESS Study: evaluation of Acute Candesartan Cilexetil Therapy in Acute Stroke Survivors. Stroke. 2003; 34:1699–1703.LinkGoogle Scholar21. Hankey GJ. Lowering blood pressure in acute stroke: the SCAST trial. Lancet. 2011; 377:696–698.CrossrefMedlineGoogle Scholar22. Anderson CS, Huang Y, Wang JG, Arima H, Neal B, Peng B , et al; for the INTERACT Investigators. Intensive blood pressure reduction in acute cerebral haemorrhage trial (INTERACT): a randomised pilot trial. Lancet Neurol. 2008; 7:391–399.CrossrefMedlineGoogle Scholar23. Delcourt C, Huang Y, Wang J, Heeley E, Lindley R, Stapf C , et al; INTERACT2 Investigators. The second (main) phase of an open, randomised, multicentre study to investigate the effectiveness of an intensive blood pressure reduction in acute cerebral haemorrhage trial (INTERACT2). Int J Stroke. 2010; 5:110–116.CrossrefMedlineGoogle Scholar24. PROGRESS Collaborative Group. Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6105 individuals with previous stroke or transient ischaemic attack. Lancet. 2001; 358:1033–1041.CrossrefMedlineGoogle Scholar25. Robinson TG, Potter JF, Ford GA, Bulpitt CJ, Jagger C, James MA , et al; on behalf of the COSACS Investigators. Effects of antihypertensive treatment after acute stroke in the Continue Or Stop post-Stroke Antihypertensives Collaborative Study (COSSACS): a prospective, randomised, open, blinded-endpoint trial. Lancet Neurol. 2010; 9:767–775.CrossrefMedlineGoogle Scholar26. Potter JF, Robinson TG, Ford GA, Mistri A, James M, Chernova J, et al. Controlling Hypertension and Hypotension Immediately Post-Stroke (CHHIPS): a randomised, placebo-controlled, double-blind pilot trial. Lancet Neurol. 2009; 8:48–56.CrossrefMedlineGoogle Scholar27. Fischer U, Bull LE, Silver LM, Mehta Z, Rothwell PM. Acute blood pressure after TIA and stroke in relation to pathological subtype, severity, and premorbid measurements: population based study [Abstract]. Cerebrovasc Dis. 2011; 31(suppl 2):73.Google Scholar28. Rothwell PM. Limitations of the usual blood pressure hypothesis and the importance of variability, instability and episodic hypertension. Lancet. 2010; 375:938–948.CrossrefMedlineGoogle Scholar29. Rothwell PM, Howard SC, Dolan E, O'Brian E, Dobson JE, Dahlöf B, et al. Prognostic significance of visit-to-visit variability, maximum systolic blood pressure, and episodic hypertension. Lancet. 2010; 375:895–905.CrossrefMedlineGoogle Scholar30. Rothwell PM, Howard SC, Dolan E, O'Brian E, Dobson JE, Dahlöf B, et al. Effects of beta-blockers and calcium channel blockers on within-individual variability in blood and risk of stroke. Lancet Neurol. 2010; 9:469–480.CrossrefMedlineGoogle Scholar31. Lavallée PC, Meseguer E, Abboud H, Cabrejo L, Simon O, Mazighi M, et al. A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects. Lancet Neurol. 2007; 6:953–960.CrossrefMedlineGoogle Scholar32. Rothwell PM, Giles MF, Chandratheva A, Marquardt L, Geraghty O , et al; on behalf of the Early use of Existing Preventive Strategies for Stroke (EXPRESS) Study. Major reduction in risk of early recurrent stroke by urgent treatment of TIA and minor stroke: EXPRESS Study. Lancet2007; 370:1432–1442.CrossrefMedlineGoogle Scholar33. Webb AJS, Fischer U, Mehta Z, Rothwell PM. Effects of antihypertensive drug class on inter-individual variation in blood pressure: a systematic review and meta-analysis. Lancet. 2010; 375:906–915.CrossrefMedlineGoogle Scholar34. Rha JH, Saver JL. The impact of recanalisation on ischaemic stroke outcome: a meta-analysis. Stroke. 2007; 38:967–973.LinkGoogle Scholar35. Martin-Schild S, Hallevi H, Albright KC, Khaja AM, Barreto AD, Gonzales NR, et al. Aggressive blood pressure-lowering treatment before intravenous tissue plasminogen activator therapy in acute ischaemic stroke. Arch Neurol. 2008; 65:1174–1178.CrossrefMedlineGoogle Scholar36. The ENOS Trial Investigators. Glyceryl trinitrate vs control, and continuing vs stopping temporarily prior antihypertensive therapy, in acute stroke: rationale and design of the Efficacy of Nitric Oxide in Stroke (ENOS) trial (ISRCTN99414122). Int J Stroke. 2006; 1:245–249.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Hurford R, Sekhar A, Hughes T and Muir K (2020) Diagnosis and management of acute ischaemic stroke, Practical Neurology, 10.1136/practneurol-2020-002557, 20:4, (304-316), Online publication date: 1-Aug-2020. Kilic İ, Hakeem A, Marmagkiolis K, Paixao A, Grunwald I, Mutlu D, AbouSherif S, Gundogdu B, Kulaksizoglu S, Ates I, Wholey M, Goktekin O and Cilingiroglu M (2019) Endovascular Therapy for Acute Ischemic Stroke: A Comprehensive Review of Current Status, Cardiovascular Revascularization Medicine, 10.1016/j.carrev.2018.07.010, 20:5, (424-431), Online publication date: 1-May-2019. Park C, Park J, Kim Y, Yoon Y, Lee S, Kim H, Kim Y, Cho G, Sohn D and Lee S (2018) Left Ventricular Geometry Determines Prognosis and Reverse J-Shaped Relation Between Blood Pressure and Mortality in Ischemic Stroke Patients, JACC: Cardiovascular Imaging, 10.1016/j.jcmg.2017.02.015, 11:3, (373-382), Online publication date: 1-Mar-2018. Zhang Y, Liu Y, Hang J, Geng C, Shi G, Zhou J and Yang J (2016) Intensive or standard: a meta-analysis of blood pressure lowering for cerebral haemorrhage, Neurological Research, 10.1080/01616412.2016.1258204, 39:1, (83-89), Online publication date: 2-Jan-2017. Buratti L, Cagnetti C, Balucani C, Viticchi G, Falsetti L, Luzzi S, Lattanzi S, Provinciali L and Silvestrini M (2014) Blood pressure variability and stroke outcome in patients with internal carotid artery occlusion, Journal of the Neurological Sciences, 10.1016/j.jns.2014.02.007, 339:1-2, (164-168), Online publication date: 1-Apr-2014. Fischer U, Cooney M, Bull L, Silver L, Chalmers J, Anderson C, Mehta Z and Rothwell P (2014) Acute post-stroke blood pressure relative to premorbid levels in intracerebral haemorrhage versus major ischaemic stroke: a population-based study, The Lancet Neurology, 10.1016/S1474-4422(14)70031-6, 13:4, (374-384), Online publication date: 1-Apr-2014. Miller J, Kinni H, Lewandowski C, Nowak R and Levy P (2014) Management of Hypertension in Stroke, Annals of Emergency Medicine, 10.1016/j.annemergmed.2014.03.004, 64:3, (248-255), Online publication date: 1-Sep-2014. Hubert G, Müller-Barna P and Haberl R (2013) Unsolved Issues in the Management of High Blood Pressure in Acute Ischemic Stroke, International Journal of Hypertension, 10.1155/2013/349782, 2013, (1-5), . Cheren'ko T and Heletyuk Y (2017) INFLUENCE OF ARTERIAL HYPERTENSION WITH DIFFERENT DURATION ON NEUROLOGICAL AND FUNCTIONAL OUTCOME OF ISCHEMIC STROKE, Medical Science of Ukraine (MSU), 10.32345/2664-4738.1-2.2017.06, 13:1-2, (41-48) October 2011Vol 42, Issue 10 Advertisement Article InformationMetrics © 2011 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.111.619346PMID: 21852619 Manuscript receivedJune 6, 2011Manuscript acceptedJune 8, 2011Originally publishedAugust 18, 2011 Keywordshypertensionacute stroketherapyPDF download Advertisement SubjectsCardiopulmonary Resuscitation and Emergency Cardiac CareCerebrovascular Disease/StrokeClinical StudiesTreatment
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