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Published on: February 10, 2023
Interventions for deliberately altering blood pressure in acute stroke
Chamila Geeganage1, Philip M W Bath
1Division of Stroke Medicine, University of Nottingham, South Block D Floor, Queens Medical Centre, Nottingham, UK, NG7 2UH.
Insights
Altering blood pressure in acute stroke patients with medications like calcium channel blockers, ACE inhibitors, ARA, and GTN did not improve outcomes. More research is needed to determine the effects of blood pressure management in acute stroke.
Area of Science:
- Neurology
- Cardiovascular Medicine
- Clinical Trials
Background:
- The optimal management of blood pressure during the acute phase of stroke remains uncertain.
- This review is an updated analysis of previous Cochrane reviews on this topic, first published in 1997 and updated in 2001.
Purpose of the Study:
- To evaluate the impact of modifying blood pressure in individuals experiencing acute stroke.
- To assess the effects of various vasoactive drugs on blood pressure levels in acute stroke patients.
Main Methods:
- Conducted a systematic review of randomized controlled trials (RCTs) involving interventions to alter blood pressure within one week of acute ischemic or hemorrhagic stroke.
- Searched multiple databases including Cochrane, MEDLINE, and EMBASE, alongside reference lists and expert consultations.
- Two independent reviewers assessed trial eligibility, quality, and extracted data.
Main Results:
- Twelve trials with 1153 participants were analyzed. Medications included ACE inhibitors (ACEI), angiotensin receptor antagonists (ARA), calcium channel blockers (CCBs), glyceryl trinitrate (GTN), and phenylephrine.
- ACEI, ARA, CCBs, and GTN demonstrated a reduction in systolic and diastolic blood pressure.
- Phenylephrine showed a non-significant increase in blood pressure. Importantly, none of the tested interventions significantly altered functional outcomes or mortality.
Conclusions:
- There is currently insufficient evidence to conclude whether altering blood pressure in the acute phase of stroke impacts patient outcomes.
- Specific antihypertensive drugs like CCBs, ACEI, ARA, and GTN effectively lower blood pressure in acute stroke.
- Phenylephrine appears to increase blood pressure in this context, though evidence is limited.
Background:
It is unclear whether blood pressure should be altered actively during the acute phase of stroke. This is an update of a Cochrane review first published in 1997, and previously updated in 2001.
Objectives:
To assess the effect of altering 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 Stroke Group Trials Register (last searched July 2007), the Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2 2008), MEDLINE, EMBASE and other databases, reference lists of relevant publications and contacted researchers in the field.
Selection Criteria:
Randomised controlled trials of interventions that aimed to alter blood pressure in patients within one week of acute ischaemic or haemorrhagic stroke.
Data Collection And Analysis:
Two review authors independently applied the inclusion criteria, assessed trial quality and extracted data.
Main Results:
Twelve trials involving 1153 participants were included (603 participants were assigned active therapy and 550 participants received placebo/control). The trials tested angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor antagonists (ARA), calcium channel blockers (CCBs), clonidine, glyceryl trinitrate (GTN), thiazide diuretic and mixed antihypertensive therapy. One trial tested phenylephrine. At 24 hours after randomisation ACEIs reduced systolic blood pressure (SBP, mean difference, MD -6 mmHg, 95% confidence interval, CI -22 to 10) and diastolic blood pressure (DBP, MD -5 mmHg, 95% CI -18 to 7), ARA reduced SBP (MD -3, 95% CI -7 to 2) and DBP (MD -3, 95% CI -6 to 0.4), iv CCBs reduced SBP (MD -32 mmHg, 95% CI -65 to 1) and DBP (MD -13 mmHg, 95% CI -31 to 6), oral CCBs reduced SBP (MD -13 mmHg, 95% , CI -43 to 17) and DBP (MD -6 mmHg, 95% CI -14 to 2), GTN reduced SBP (MD -10 mmHg, 95% CI -18 to -3) and DBP (MD -1 mmHg, 95% CI -5 to 3) while phenylephrine, non-significantly increased SBP (MD 21 mmHg, 95% CI -13 to 55) and DBP (MD 1 mmHg, 95% CI -15 to 16). Functional outcome and death were not altered by any of the drugs.
Authors' Conclusions:
There is insufficient evidence to evaluate the effect of altering blood pressure on outcome during the acute phase of stroke. In patients with acute stroke, CCBs, ACEI, ARA and GTN each lower blood pressure while phenylephrine probably increases blood pressure.
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Monitoring BP in both arms during the initial assessment is advisable, as the systolic value may differ by five to ten mm Hg between arms. For subsequent BP assessments, use the arm with the higher reading.