Vasoactive drugs for acute stroke
Chamila Geeganage1, Philip Mw Bath
1Division of Stroke Medicine, University of Nottingham, Nottingham City Hospital Campus, Hucknall Road, Nottingham, UK, NG5 1PB.
Insights
Altering blood pressure (BP) in acute stroke is not well-supported by evidence. While some drugs lower BP, diaspirin cross-linked hemoglobin (DCLHb) increased poor outcomes, suggesting caution with BP-raising agents.
Area of Science:
- Neurology
- Cardiovascular Medicine
- Clinical Pharmacology
Background:
- The management of blood pressure (BP) during the acute phase of stroke remains uncertain.
- Optimal BP targets and interventions require further investigation.
Purpose of the Study:
- To evaluate the impact of modifying blood pressure (BP) in patients experiencing acute stroke.
- To assess the effects of various vasoactive medications on BP levels in acute stroke.
Main Methods:
- A systematic review of randomized controlled trials was conducted, searching multiple databases up to October 2009.
- Included trials involved interventions expected to alter BP in patients within one week of acute stroke onset.
- Data from 43 trials involving 7649 patients were analyzed.
Main Results:
- Beta receptor antagonists, calcium channel blockers (CCBs), nitric oxide donors, and prostacyclin effectively lowered BP in acute stroke.
- Diaspirin cross-linked hemoglobin (DCLHb) significantly increased BP.
- Only DCLHb demonstrated a significant impact on outcomes, worsening combined death or dependency.
Conclusions:
- Insufficient evidence exists to reliably determine the effects of altering BP on outcomes following acute stroke.
- Treatment with DCLHb is associated with adverse clinical outcomes.
- Specific BP-lowering agents like beta receptor antagonists and CCBs reduced BP during acute stroke, but their impact on overall outcomes needs further study.
Background:
It is unclear whether blood pressure (BP) should be altered actively during the acute phase of stroke.
Objectives:
To assess the effect of lowering or elevating BP in people with acute stroke, and the effect of different vasoactive drugs on BP in acute stroke.
Search Strategy:
We searched the Cochrane Stroke Group Trials Register (last searched June 2009), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2009), MEDLINE (1966 to October 2009), EMBASE (1980 to October 2009), and Science Citation Index (1981 to October 2009).
Selection Criteria:
Randomised trials of interventions that would be expected, on pharmacological grounds, to alter BP in patients within one week of the onset of acute stroke.
Data Collection And Analysis:
Two review authors independently applied the trial inclusion criteria, assessed trial quality, and extracted data.
Main Results:
We identified 131 trials involving in excess of 18,000 patients; a further 13 trials are ongoing. We obtained data for 43 trials (7649 patients). Among BP-lowering trials, beta receptor antagonists lowered BP (early systolic BP (SBP) mean difference (MD) -6.1 mmHg, 95% CI -11.4 to -0.9; late SBP MD -4.9 mmHg, 95% CI -10.2 to 0.4; late diastolic BP (DBP) MD -4.5 mmHg, 95% CI -7.8 to -1.2). Oral calcium channel blockers (CCB) lowered BP (late SBP MD -3.2 mmHg, 95% CI -5.4 to -1.1; early DBP MD -2.5, 95% CI -5.6 to 0.7; late DBP MD -2.1, 95% CI -3.5 to -0.7). Nitric oxide donors lowered BP (early SBP MD -10.3 mmHg, 95% CI -17.6 to -3.0). Prostacyclin lowered BP (late SBP MD, -7.7 mmHg, 95% CI -15.6 to 0.2; late DBP MD -3.9 mmHg, 95% CI -8.1 to 0.4). Among BP-increasing trials, diaspirin cross-linked haemoglobin (DCLHb) increased BP (early SBP MD 15.3 mmHg, 95% CI 4.0 to 26.6; late SBP MD 15.9 mmHg, 95% CI 1.8 to 30.0). None of the drug classes significantly altered outcome apart from DCLHb which increased combined death or dependency (odds ratio (OR) 5.41, 95% CI 1.87 to 15.64).
Authors' Conclusions:
There is not enough evidence to evaluate reliably the effect of altering BP on outcome after acute stroke. However, treatment with DCLHb was associated with poor clinical outcomes. Beta receptor antagonists, CCBs, nitric oxide, and prostacyclin each lowered BP during the acute phase of stroke. In contrast, DCLHb increased BP.
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