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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.
On Twitter @mitchelzoler
Elevated blood pressure occurs in most patients with acute ischemic stroke, and it may be harmful but might also be protective. The results of this study, the largest reported trial of blood pressure management in acute ischemic stroke patients, add something to our clinical judgment for the subset of patients who match those enrolled in the study: patients beyond the hyper-acute phase with a mild stroke (average NIH Stroke Scale score of 4), no major-vessel occlusions, moderately elevated blood pressure, and no reperfusion treatment.
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Mitchel L. Zoler/IMNG Medical Media
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In this trial, an average blood pressure reduction of 12.7% after 24 hours did not improve the primary endpoint but it did not worsen recovery. That is reassuring. It shows that we can push the envelope a little in our use of blood pressure reduction. In current U.S. practice, some clinicians will try to reduce blood pressure in patients with moderately elevated pressure. Many U.S. stroke units are comfortable with blood pressure monitoring and with the target of less than 180 mm Hg used for patients treated with tissue plasminogen activator. These protocols are often also applied to ischemic stroke patients not treated with fibrinolysis because it is part of their usual practice.
My take on the findings is that, for the types of patients enrolled in this study, this strategy of more active blood pressure management to get pressure down to a goal level could be a safe option.
Dr. Cathy Sila is professor of neurology and director of the stroke and cerebrovascular center at Case Medical Center in Cleveland. She made these comments as the designated discussant for the report and in an interview.
Elevated blood pressure occurs in most patients with acute ischemic stroke, and it may be harmful but might also be protective. The results of this study, the largest reported trial of blood pressure management in acute ischemic stroke patients, add something to our clinical judgment for the subset of patients who match those enrolled in the study: patients beyond the hyper-acute phase with a mild stroke (average NIH Stroke Scale score of 4), no major-vessel occlusions, moderately elevated blood pressure, and no reperfusion treatment.
|
Mitchel L. Zoler/IMNG Medical Media
|
In this trial, an average blood pressure reduction of 12.7% after 24 hours did not improve the primary endpoint but it did not worsen recovery. That is reassuring. It shows that we can push the envelope a little in our use of blood pressure reduction. In current U.S. practice, some clinicians will try to reduce blood pressure in patients with moderately elevated pressure. Many U.S. stroke units are comfortable with blood pressure monitoring and with the target of less than 180 mm Hg used for patients treated with tissue plasminogen activator. These protocols are often also applied to ischemic stroke patients not treated with fibrinolysis because it is part of their usual practice.
My take on the findings is that, for the types of patients enrolled in this study, this strategy of more active blood pressure management to get pressure down to a goal level could be a safe option.
Dr. Cathy Sila is professor of neurology and director of the stroke and cerebrovascular center at Case Medical Center in Cleveland. She made these comments as the designated discussant for the report and in an interview.
Elevated blood pressure occurs in most patients with acute ischemic stroke, and it may be harmful but might also be protective. The results of this study, the largest reported trial of blood pressure management in acute ischemic stroke patients, add something to our clinical judgment for the subset of patients who match those enrolled in the study: patients beyond the hyper-acute phase with a mild stroke (average NIH Stroke Scale score of 4), no major-vessel occlusions, moderately elevated blood pressure, and no reperfusion treatment.
|
Mitchel L. Zoler/IMNG Medical Media
|
In this trial, an average blood pressure reduction of 12.7% after 24 hours did not improve the primary endpoint but it did not worsen recovery. That is reassuring. It shows that we can push the envelope a little in our use of blood pressure reduction. In current U.S. practice, some clinicians will try to reduce blood pressure in patients with moderately elevated pressure. Many U.S. stroke units are comfortable with blood pressure monitoring and with the target of less than 180 mm Hg used for patients treated with tissue plasminogen activator. These protocols are often also applied to ischemic stroke patients not treated with fibrinolysis because it is part of their usual practice.
My take on the findings is that, for the types of patients enrolled in this study, this strategy of more active blood pressure management to get pressure down to a goal level could be a safe option.
Dr. Cathy Sila is professor of neurology and director of the stroke and cerebrovascular center at Case Medical Center in Cleveland. She made these comments as the designated discussant for the report and in an interview.
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.
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.
On Twitter @mitchelzoler
AT THE AHA SCIENTIFIC SESSIONS
Major finding: Blood pressure lowering resulted in a similar rate of death and major disability as placebo after 14 days.
Data source: The CATIS trial randomized 4,071 patients with mild acute ischemic strokes to a blood pressure-lowering strategy or placebo at 26 Chinese hospitals.
Disclosures: Dr. He and Dr. Sila said that they had no disclosures.
