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Vasoactive drugs for acute stroke
1Division of Stroke Medicine, University of Nottingham, City Hospital Campus, Hucknall Road, Nottingham, Nottinghamshire, UK, NG5 1PB. philip.bath@nottingham.ac.uk
Insights
Managing blood pressure after acute stroke remains unclear. While some drugs like calcium channel blockers (CCBs) and beta blockers lower blood pressure, evidence is insufficient to determine their effect on stroke outcomes.
Area of Science:
- Neurology
- Cardiovascular Medicine
- Clinical Pharmacology
Background:
- The optimal management of blood pressure following acute stroke is not well-established.
- Uncertainty exists regarding whether blood pressure should be lowered or elevated post-stroke.
Purpose of the Study:
- To evaluate the impact of altering blood pressure in acute stroke patients.
- To assess the efficacy of various vasoactive drugs on blood pressure during acute stroke.
Main Methods:
- Systematic review of randomized controlled trials (RCTs) investigating blood pressure interventions within two weeks of stroke onset.
- Searched multiple databases including Cochrane Library, MEDLINE, and EMBASE, supplemented by contacting researchers and pharmaceutical companies.
- Data extraction and quality assessment were performed independently by two reviewers.
Main Results:
- Thirty-two trials involving 5,368 patients were analyzed; significant baseline blood pressure imbalances complicated interpretation.
- Intravenous and oral calcium channel blockers (CCBs) significantly reduced late blood pressure. Beta blockers lowered diastolic pressure but not systolic.
- No drug classes significantly altered stroke outcomes, though beta blockers and streptokinase increased early case fatality.
Conclusions:
- Insufficient evidence exists to reliably assess the effect of blood pressure modulation on acute stroke outcomes.
- CCBs, beta blockers, ACE-inhibitors, prostacyclin, and nitric oxide demonstrated blood pressure-lowering effects during acute stroke.
- Magnesium, naftidrofuryl, and piracetam showed minimal to no impact on blood pressure.
Background:
It is unclear whether blood pressure should be managed after acute stroke and if so whether it is best to reduce or increase blood pressure.
Objectives:
The objective of this review was to assess the effect of lowering or elevating blood pressure in people with acute stroke, and the effect of different vasoactive drugs on blood pressure in acute stroke.
Search Strategy:
We searched the Cochrane Library (1999 Issue 1) using the CDSR and the CCTR databases, MEDLINE (from 1966), EMBASE (from 1980), BIDS ISI (Science Citation Index from 1981), and existing review articles. We contacted researchers in the field and pharmaceutical companies.
Selection Criteria:
Randomised trials of interventions that would be expected, on pharmacological grounds, to alter blood pressure in patients within two weeks of the onset of acute ischaemic or haemorrhagic stroke.
Data Collection And Analysis:
Two reviewers independently applied the trial inclusion criteria, assessed trial quality, and extracted the data.
Main Results:
Sixty five trials were identified involving in excess of 11,500 patients; a further 5 trials are ongoing. Data were obtained for 32 trials (5,368 patients). Significant imbalances in baseline blood pressure were present across trials of intravenous calcium channel blockers and prostacyclin. Major imbalances in baseline blood pressure between treatment and control groups have made the interpretation of these results difficult. Intravenous calcium channel blockers (CCBs) and oral CCBs significantly lowered late blood pressure as compared to controls. (systolic/diastolic BP): iv CCBs -8.2/-6.7 mm Hg (95% CI -12.6 to -3.8)/ (95% CI -9.2 to -4.3); oral CCBs -3.2/-2.1 mm Hg (95% CI -5.0 to -1.3)/ (95% CI -3.0 to -1.0). Beta blockers significantly lowered late diastolic blood pressure but not significantly late systolic blood pressure; -5.0/-4.5 mm Hg (95% CI -10.2 to 0.4)/(95% CI -7.8 to -1.15). Angiotensin converting enzyme inhibitors and prostacyclin non-significantly reduced late BP as compared to the controls by -5.4/-3.0 mm Hg (95% CI -16.5 to 5.8)/(95% CI -11.1 to 5.0) and -7.4/-3.9 mmHg (95% CI -15.6 to 0.2)/(95% CI -8.1 to 0.4) respectively. Magnesium, naftidrofuryl and piracetam had no significant effect on blood pressure. Oral CCBs and beta blockers each significantly reduced late heart rate (beats per minute (bpm)): CCBs -2.8 bpm (95%CI -3.9 to -1.7); beta blockers -9.3 bpm (95% CI -12.0 to -6.6). Prostacyclin significantly increased late heart rate by +5.6 bpm (95% CI 0.8 to 10.4). None of the drug classes significantly altered outcome apart from beta blockers and streptokinase which increased early case fatality (odds ratio 1.77, 95%CI, 1.05 to 3.00) and 2.27 (95% CI 1.4 to 3.67).
Reviewer'S Conclusions:
There is not enough evidence reliably to evaluate the effect of altering blood pressure on outcome after acute stroke. CCBs, beta blockers, and probably ACE-inhibitors, prostacyclin and nitric oxide, each lowered BP during the acute phase of stroke. In contrast, magnesium, naftidrofuryl and piracetam had little or no effect on BP.