Allison E. Arch, MD
Does anyone know how to optimally manage blood pressure during the first 24 hours after acute ischemic stroke?

Berge, et al., addressed the complex question of blood pressure and acute ischemic stroke in an analysis of patients enrolled in the Third International Stroke Trial (IST-3). The IST-3 was a randomized trial comparing recombinant plasminogen activator (rt-PA) to open control within 6 hours of symptom onset. Berge and colleagues used this population to study the short- and long-term effects of blood pressure and blood pressure lowering treatment in acute stroke. Blood pressure was measured at randomization, at the start of treatment, and at 30 minutes, 1 hour, and 24 hours after the start of treatment. The use of anti-hypertensive medications within the first 24 hours was also recorded. The primary clinical outcomes were early adverse events, early death, and functional outcome at 6 months.

The authors found that high baseline blood pressure and high blood pressure variability during the first 24 hours were associated with increased numbers of adverse events and early deaths. Functional outcome at 6 months was improved in patients who were given anti-hypertensive medications during the first 24 hours, and in those who had a larger decline in blood pressure in the acute post-stroke period. The one negative outcome of a lower blood pressure was recurrent ischemic stroke: a large decline in systolic blood pressure during the first 24 hours showed a non-significant higher risk of early recurrent ischemic stroke. However, all other outcomes, including clinical outcome at 6 month, were improved if blood pressure was lowered acutely (although not all were statistically significant).

This was not a randomized controlled trial and instead used a patient population that was enrolled in an entirely different study. It is therefore subject to the bias and confounding factors that can plague observational studies. However, the results are nonetheless intriguing and offer a different perspective on acute blood pressure management following ischemic stroke. Is it time to put an end to “permissive hypertension” in the early post-stroke period?