Chirantan Banerjee, MD

Lee M, Ovbiagele B, Hong KS, Wu YL, Lee JE, Rao NM, et al. Effect of Blood Pressure Lowering in Early Ischemic Stroke: Meta-Analysis. Stroke. 2015 

Blood Pressure (BP) control acutely after an ischemic stroke has been a matter of debate for decades. High blood pressure is common after an acute ischemic stroke, especially in patients with premorbid hypertension. Although a number of studies, both retrospective and prospective have examined the relationship between blood pressure lowering acutely after stroke and outcome, there is no clear consensus, as the results have been inconsistent. This may be secondary to the fact that every patient’s optimal blood pressure acutely after a stroke is likely different, contingent on vessel status, stroke etiology and severity. Data from IST-3 showed a U-shaped curve between admission BP and functional outcome. Based on results of the COSSACS study, the 2013 AHA guidelines posited that initiation of antihypertensive therapy within 24 hours of stroke is relatively safe in patients who have hypertension and are neurologically stable unless a specific contraindication to restarting treatment is known. But we lack Class I evidence to answer if blood pressure lowering is beneficial or harmful acutely after a stroke. 

In the current study, Lee et al performed a meta-analysis of 12 randomized clinical trials using random effects modeling, comparing active lowering of blood pressure beyond 3 days versus control, which included discontinuation or continuation of home blood pressure medications without addition of a new agent. For the primary outcome of death or dependency (mRS 3-6) at 3 months or at trial end point, there was no difference between the two groups (RR 1.04, 0.96-1.13). The main limitation of the study is that there was no stroke subtyping possible, which may be very important, as large vessel, lacunar, and embolic strokes likely respond differently to blood pressure lowering.

While we wait for future trials like ENCHANTED, this meta-analysis echoes that active blood pressure reduction starting ~3 days after acute ischemic stroke is safe and reasonable.