Blood Pressure Reduction Time Windows in Stroke: A Systematic Review and Network Meta-Analysis

The optimal time windows for blood pressure reduction (BPR) treatment in patients with stroke remain controversial. This systematic review and network meta-analysis (NMA) evaluates the efficacy of different BPR time windows across stroke subtypes and assesses associated safety outcomes.

A systematic review of RCTs was conducted using PubMed, Embase, Cochrane Central Register of Controlled Trials, and Web of Science from their inception to March 21, 2026. Eligible trials enrolled patients with stroke treated with BPR. The primary outcome was mortality during follow-up. Confidence in Network Meta-Analysis (CINeMA) and the Cochrane Risk of Bias tool were used to assess quality. A random-effects meta-analysis model was employed to pool the odds ratios (ORs) and mean differences, with their corresponding 95% confidence intervals (CIs) reported.

A total of 31 randomized controlled trials (RCTs), including 29,276 patients, were included. For ischemic stroke (IS) patients (13 RCTs, n = 17,220), prehospital BPR therapy was associated with increased mortality risk compared with the reference (OR 1.28, 95% CI [1.01, 1.61]) and the 48 h window (OR 1.34, 95% CI [1.01, 1.77]). In intracerebral hemorrhage (ICH) patients (13 RCTs, n = 6826) and unspecified stroke patients (13 RCTs, n = 13,323), BPR therapy had no significant impact on mortality at any time window. Subgroup analyses were consistent with the primary findings.

This NMA suggests a potential association between prehospital BPR treatment and increased risk of stroke mortality in IS patients versus the reference and within 48 h BPR groups, although evidence confidence is limited. These findings support cautious prehospital BPR use pending stroke subtype confirmation and highlight the need for further high-quality studies.