Interventions for Deliberately Altering Blood Pressure in Acute Stroke

BACKGROUNDIt is unclear whether hypertension should be treated during the acute phase of stroke, and some have hypothesised that blood pressure should be increased to improve cerebral perfusion.OBJECTIVESThe objective of this review was to assess the effect of lowering or elevating blood pressure in people with acute stroke, and the effect of different vasoactive drugs on blood pressure in acute stroke.SEARCH STRATEGYWe searched the Cochrane Library (2000 Issue 3 ) using the CDSR and the CCTR databases, MEDLINE (from 1966), EMBASE (from 1980), BIDS ISI (Science Citation Index from 1981), and existing review articles. We contacted researchers in the field and pharmaceutical companies. We handsearched the Ongoing Trials section of the journal Stroke and scanned the reference lists of existing review articles.SELECTION CRITERIARandomised trials of interventions that aimed to alter blood pressure in patients within two weeks of acute ischaemic or haemorrhagic stroke.DATA COLLECTION AND ANALYSISTwo reviewers independently applied the inclusion criteria and assessed trial quality. Two reviewers extracted the data.MAIN RESULTSFive trials involving 218 patients were included. The trials tested the following vasodilators: nimodipine (66 patients), nicardipine (5), captopril (3), clonidine (2), glyceryl trinitrate (16) and perindopril (14); 92 subjects received placebo/control treatment. Oral calcium channel blockers (CCB's), nimodipine and nicardipine reduced systolic blood pressure (weighted mean difference 10.9mmHg, 95% confidence interval 2.0 to 19.7), diastolic blood pressure (weighted mean difference 9.5mmHg, 95% confidence interval 4.0 to 15.1) and heart rate (weighted mean difference 4.7 beats per minute, 95% confidence interval 0.2 to 9.2) at 48 hours. The greatest fall in blood pressure over the first 24 hours was shown in patients given the highest dose of nimodipine. ACE-I (angiotensin converting enzyme inhibitors), perindopril and captopril reduced systolic blood pressure (weighted mean difference 15.0 mmHg, 95% confidence interval -0.6 to 30.6) and diastolic blood pressure (weighted mean difference 11.8 mmHg (weighted mean difference 95% confidence interval 4.2 to 19.4) at 24 hours. Glyceryl trinitrate showed a non significant reduction in blood pressure at 24 hours. None of the drugs significantly affected outcome. The limited amount of data made it impossible to assess the relationship between change in blood pressure and clinical outcome. No completed studies of interventions to raise blood pressure were identified.REVIEWER'S CONCLUSIONSThere is not enough evidence to evaluate the effect of altering blood pressure on outcome during the acute phase of stroke. Oral CCB's, ACE inhibitors and glyceryl trinitrate all appear to lower blood pressure in patients with acute stroke.