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Evidence summaries

Blood Pressure Alteration in Acute Stroke

Lowering of blood pressure in acute stroke does not have effect on survival or functional outcome. Level of evidence: "A"

A Cochrane review [Abstract] 1 included 26 studies with a total of 17 011 subjects. The patients were enrolled within one week of acute ischaemic or haemorrhagic stroke. Most data came from trials that had a wide time window for recruitment; 4 trials gave treatment within 6 hours and one trial within 8 hours. The trials tested alpha-2 adrenergic agonists (A2AA), angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor antagonists (ARA), calcium channel blockers (CCBs), nitric oxide (NO) donors, thiazide-like diuretics and target-driven blood pressure lowering.At 24 hours after randomisation the reduction in systolic blood pressure (SBP) and diastolic blood pressure were as follow for different treatments.

  • Oral ACEIs: SBP: MD -8 mmHg (95% CI -17 to 1; 5 studies, n=120) and DBP: MD -3 mmHg (95% CI -9 to 2; 4 studies, n=96)
  • Sublingual ACEIs: SBP: MD -12.00 mm Hg (95% CI -26 to 2; 1 study, n=42) and DBP: MD -2 (95%CI -10 to 6; 1 study, n=42)
  • Oral ARAs: SBP: MD -1 mm Hg (95% CI -3 to 2; 2 studies, n=2368) and DBP: MD -1 mm Hg (95% CI -3 to 1; 2 studies, n=2368)
  • Oral beta blockers: SBP: MD -14 mm Hg (95% CI -27 to -1; one stydy, n=44) and DBP: MD -1 mm Hg (95% CI -9 to 7; one study, n=43)
  • Intravenous (iv) beta blockers: SBP: MD -5 mm Hg (95% CI -18 to 8; one study, n=43) and DBP: -5 mm Hg (95% CI -13 to 3; one study, n=43)
  • Oral CCBs: SBP: MD -13 mmHg (95% CI -43 to 17; 2 studies, n=84) and DBP: MD -6 mmHg (95% CI -14 to 2; 2 studies, n=84)
  • Iv CCBs: SBP: MD -32 mmHg (95% CI -65 to 1; one study, n=11) and DBP: MD -13 (95% CI -31 to 6; one study, n=11)
  • NO donors: SBP: MD -12 mmHg (95% CI -19 to -5; 7 studies, n=4183) and DBP: MD -3 (95% CI -4 to -2; 7 studies, n=4197)

Blood pressure lowering did not reduce death or dependency either by drug class (OR 0.98, 95% CI 0.92 to 1.05; 16 studies, n=15 489), stroke type (OR 0.98, 95% CI 0.92 to 1.05; 16 trials, n=15 366) or time to treatment (OR 0.98, 95% CI 0.92 to 1.05; 16 trials, n=15 489). Treatment within 6 hours of stroke appeared effective in reducing death or dependency (OR 0.86, 95% CI 0.76 to 0.99; 15 studies, n=15 520) but not death (OR 0.70, 95% CI 0.38 to 1.26; 3 studies, n=3056) at the end of the trial. Although death or dependency did not differ between people who continued pre-stroke antihypertensive treatment vs. those who stopped it temporarily (worse outcome with continuing treatment, OR 1.06, 95% CI 0.91 to 1.24; 2 studies, n=2860), disability scores at the end of the trial were worse for patients randomised to continue treatment (Barthel Index: MD -3.2, 95% CI -5.8, -0.6; 2 studies, n=2860).

    References

    • Bath PM, Krishnan K. Interventions for deliberately altering blood pressure in acute stroke. Cochrane Database Syst Rev 2014;10():CD000039. [PubMed].

Primary/Secondary Keywords