Does early antihypertensive treatment prevent death in stroke patients?

Early antihypertensive treatment appears to have no significant benefits in terms of dependency or death at 90 days among patients with mild-to-moderate acute ischaemic stroke and systolic blood pressure (SBP) between 140 and <220 mm Hg, reports a study.

“Therefore, initiation of antihypertensive treatment might not be beneficial in the week following acute ischaemic stroke onset,” the researchers said.

This multicentre, randomized, open-label trial was conducted in 106 hospitals in China between 13 July 2018 and 10 July 2022 to compare the effect of early antihypertensive treatment initiated within 24‒48 hours of stroke onset versus delaying treatment until day 8 on reducing dependency or death.

A total of 4,810 patients aged ≥40 years were randomly assigned to receive antihypertensive treatment immediately after randomization (aimed at reducing SBP by 10‒20 percent within the first 24 hours and a mean BP <140/90 mm Hg within 7 days) or to discontinue antihypertensives for 7 days if they were taking them, and then receive treatment on day 8 (aimed at achieving mean BP <140/90 mm Hg).

Of the patients, 2,413 received early antihypertensive treatment and 2,397 delayed treatment. The mean SBP decreased by 9.7 percent (from 162.9 to 146.4 mm Hg) in the early treatment group and by 4.9 percent (from 162.8 to 154.3 mm Hg) in the delayed treatment group within 24 h after randomization (p<0.001 for group difference). [BMJ 2023;383:e076448]

At day 7, the mean SBPs in the early and delayed treatment groups were 139.1 and 150.9 mm Hg, respectively (p<0.001 for group difference). In addition, a BP of <140/90 mm Hg was achieved by 54.6 percent of patients in the early treatment arm and 22.4 percent in the delayed treatment arm (p<0.001 for group difference).

At day 90, 12.0 percent of patients who received early treatment died or experienced a dependency (odds ratio, 1.18, 95 percent confidence interval, 0.98‒1.41; p=0.08) relative to 10.5 percent of those who received delayed treatment. Notably, the incidence of recurrent stroke or adverse events did not significantly differ between the two groups.

“Our study provides novel information about early BP management in patients with acute ischaemic stroke in several ways,” the researchers said.

In previous trials, early antihypertensive treatment within 48 hours of symptom onset showed a neutral effect on dependency or death, recurrent stroke, and vascular events. [Stroke 2015;46:1883-1889]

“Our findings further show that delaying antihypertensive treatment to 8 days after stroke onset did not increase the risk of these clinical outcomes,” the researchers said. “Our study might suggest a potential harmful effect associated with early antihypertensive treatment in patients with acute ischaemic stroke.”

In another trial, however, subgroup analysis revealed that BP lower between 24 and 48 hours after stroke onset could lower the likelihood of dependency or death, recurrent stroke, and vascular events compared with no treatment among patients with acute ischaemic stroke. [JAMA 2014;311:479-489]

The current findings did not support these observations. “Additionally, previous trials did not provide antihypertensive treatment after 7‒14 days following the acute phase of ischaemic stroke,” the researchers said. [Stroke 1994;25:1348-1353; Stroke 2000;31:1250-1255; Stroke 2003;34:1699-1703]