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Early vs. Delayed Antihypertensive Treatment in Acute Ischemic Stroke

Early antihypertensive treatment was not effective in reducing the 90-day odds of functional dependency or death in patients with mild-to-moderate acute ischemic stroke and elevated systolic blood pressure (SBP), CATIS-2 researchers report. “Initiation of antihypertensive treatment might not be beneficial in the week following acute ischaemic stroke onset,” they conclude. The study was limited to patients who did not receive intravenous thrombolytic treatment because of different blood pressure treatment targets in that group.

Conducted at 106 Chinese hospitals from 2018 to 2022, the multicenter, randomized, open-label trial included 4,810 patients aged 40 years or older who were within 24-48 hours of the onset of stroke symptoms and had SBPs between 140 mm Hg and <220 mm Hg . They were randomized to immediate antihypertensive treatment aimed at reducing SBP by 10%-20% within the first 24 hours and a mean blood pressure <140/90 mm Hg within 7 days or to discontinue antihypertensive medications for 7 days if they were taking them, and then receive treatment on day 8 aimed at achieving mean blood pressure <140/90 mm Hg.

Based on a primary outcome of the combination of functional dependency or death (modified Rankin scale score ≥3) at 90 days, the study showed: “Mean systolic blood pressure was reduced by 9.7% (from 162.9 mm Hg to 146.4 mm Hg) in the early treatment group and by 4.9% (from 162.8 mm Hg to 154.3 mm Hg) in the delayed treatment group within 24 h after randomisation (P for group difference <0.001). Mean systolic blood pressure was 139.1 mm Hg in the early treatment group and 150.9 mm Hg in the delayed treatment group on day seven (P for group difference <0.001). Additionally, 54.6% of patients in the early treatment group and 22.4% in the delayed treatment group had blood pressure of less than 140/90 mm Hg (P<0.001 for group difference) on day seven. At day 90, 289 trial participants (12.0%) in the early treatment group, compared with 250 (10.5%) in the delayed treatment group, had died or experienced a dependency (odds ratio 1.18 (95% confidence interval 0.98 to 1.41), P = 0.08). No significant differences in recurrent stroke or adverse events were reported between the two groups.”

Source: BMJ