Blood Pressure Management in Acute Stroke

Whether raised blood pressure in patients with acute stroke should be treated is one of the major unresolved issues in acute stroke management, due mainly to a paucity of reliable data from sufficiently powered randomized controlled trials. However, the Scandinavian Candesartan Acute Stroke Trial (SCAST), recently published in The Lancet , adds important new information about the risks and benefits of treatment of poststroke hypertension.1 Else Sandset and colleagues assessed whether careful blood pressure-lowering treatment with candesartan is beneficial in a wide range of patients with acute ischemic and hemorrhagic stroke and raised blood pressure. Rationale for Blood Pressure-Lowering in Acute StrokeBlood pressure is increased in up to 75% to 80% of patients with acute stroke and usually decreases spontaneously over the next few days.2–4 The cause of this transient rise in blood pressure (ie, poststroke hypertension) is unknown. A specific physiological reaction to the stroke itself is often postulated, possibly due to disturbed cerebral autoregulation,5 damage or compression of brain regions that regulate the autonomic nervous system,6 or neuroendocrine factors.7,8 However, nonstroke-specific mechanisms such as headache,6 urine retention,6 infection,9 and psychological stress of admission to hospital10,11 have also been postulated.Data from observational studies have consistently shown that raised blood pressure after stroke is associated with poor short- and long-term outcomes.12–14 In patients with acute ischemic stroke, raised blood pressure is potentially harmful because it increases the risk of cerebral edema and hemorrhagic transformation in the freshly infarcted brain tissue.6 In patients with hemorrhagic stroke, high blood pressure increases the risk of hematoma expansion, growth of the perihematomal edema, and early rebleeding into the brain.15 However, optimum management of poststroke hypertension remains controversial, particularly in ischemic stroke, in which there are concerns that lowering blood …