Blood pressure in acute stroke: lower it or let the CHHIPS fall where they will
2008; Elsevier BV; Volume: 8; Issue: 1 Linguagem: Inglês
10.1016/s1474-4422(08)70264-3
ISSN1474-4465
Autores Tópico(s)Cerebrovascular and Carotid Artery Diseases
ResumoWe know little about the effect of blood pressure and its management on outcomes after stroke. A U-shaped relation between blood pressure on hospital admission and mortality has been described, 1 Vemmos KN Tsivgoulis G Spengos K et al. U-shaped relationship between mortality and admission blood pressure in patients with acute stroke. J Internal Med. 2004; 255: 257-265 Crossref Scopus (263) Google Scholar , 2 Okumura K Ohya Y Maehara A Wakugami K Iseki K Takishita S Effects of blood pressure levels on case fatality after acute stroke. J Hypertension. 2005; 23: 1217-1223 Crossref PubMed Scopus (150) Google Scholar , 3 Castillo J Leira R Garcia MM Serena J Blanco M Davalos A Blood pressure decrease during the acute phase of ischemic stroke is associated with brain injury and poor stroke outcome. Stroke. 2004; 35: 520-526 Crossref PubMed Scopus (390) Google Scholar which suggests that both low and high blood pressure contribute to worse outcomes or are markers for those patients who are likely to have a poor outcome. The range of blood pressure readings for the lowest mortality rates is not consistent across studies, and might depend on prestroke blood pressure and stroke subtype. Evidence for the benefit of the early lowering of blood pressure in acute stroke is scarce, and death associated with elevated blood pressure at admission for acute stroke has not been shown to be modifiable by reduction of blood pressure. Current guidelines for acute ischaemic stroke 4 Adams HP del Zoppo G Alberts MJ 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. Stroke. 2007; 38: 1655-1711 Crossref PubMed Scopus (1989) Google Scholar recommend withholding antihypertensive drugs from patients with ischaemic stroke who are not treated with thrombolytics unless their systolic blood pressure (SBP) is greater than 220 mm Hg or their diastolic blood pressure (DBP) is greater than 120 mm Hg, owing to insufficient data to support the safety of early lowering of blood pressure. There are several theoretical arguments against blood pressure lowering in acute ischaemic stroke, including the reduction of collateral flow and loss of tissue in the penumbra. Spontaneous reductions in blood pressure have been associated with worsening neurological status in some studies 3 Castillo J Leira R Garcia MM Serena J Blanco M Davalos A Blood pressure decrease during the acute phase of ischemic stroke is associated with brain injury and poor stroke outcome. Stroke. 2004; 35: 520-526 Crossref PubMed Scopus (390) Google Scholar , 5 Oliveira-Filho J Silva SC Trabuco CC Pedreira BB Sousa EU Bacellar A Detrimental effect of blood pressure reduction in the first 24 hours of acute stroke onset. Neurology. 2003; 61: 1047-1051 Crossref PubMed Scopus (175) Google Scholar and a better outcome in another. 6 Chamorro A Vila N Ascaso C Elices E Schonewille W Blanc R Blood pressure and functional recovery in acute ischemic stroke. Stroke. 1998; 29: 1850-1853 Crossref PubMed Scopus (130) Google Scholar The only consistent conclusion has been the need for randomised studies of antihypertensive drugs after acute stroke. Controlling hypertension and hypotension immediately post-stroke (CHHIPS): a randomised, placebo-controlled, double-blind pilot trialLabetalol and lisinopril are effective antihypertensive drugs in acute stroke that do not increase serious adverse events. Early lowering of blood pressure with lisinopril and labetalol after acute stroke seems to be a promising approach to reduce mortality and potential disability. However, in view of the small sample size, care must be taken when these results are interpreted and further evaluation in larger trials is needed. Full-Text PDF
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