Lowering blood pressure with an angiotensin-receptor blocker in patients with acute stroke and hypertension produces no benefits, according to a new study presented at the International Stroke Conference and published simultaneously online in the Lancet. In the Scandinavian Candesartan Acute Stroke Trial (SCAST), investigators randomized 2029 acute stroke patients in 9 north European countries who had a systolic blood pressure of 140 mm Hg or higher to candesartan or placebo.
At 6 months, the rate of vascular death, MI, or stroke was not significantly different between the two groups (120 events in the candesartan group versus 111 events in the placebo group, p=0.52). In addition, functional outcome at 6 months as assessed by the modified Rankin Scale was not significantly different between the groups, though a trend suggested a worse outcome in the candesartan group (p=0.048).
The investigators concluded that unless other ongoing trials suggest otherwise, “we see no place for routine blood-pressure lowering treatment in the acute phase of stroke.”
In an accompanying comment, Graeme Hankey writes that the results of the trial, taken with the results of previous trials, suggest that “pharmacologically lowering blood pressure does not have an overall beneficial effect on functional outcome” and that therefore “clinicians should… not be prescribing blood-pressure-lowering drugs within the first week of acute stroke in routine practice.”
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Here is the press release from the Lancet:
CANDESARTAN IS NOT BENEFICIAL IN PATIENTS WITH ACUTE STROKE AND HIGH BLOOD PRESSURE, AND MAY ACTUALLY BE HARMFUL
**Unusual embargo of 1100H (AM) New York time Fri 11 Feb linked to meeting**
Using the blood pressure-lowering drug candesartan in patients who have high blood pressure in the acute phase of stroke does not give any benefit, and may actually be harmful. The findings of the SCAST study are being published in an Article Online First by The Lancet that coincides with the presentation of the paper at the International Stroke Conference in Los Angeles. The study is by Dr Else Charlotte Sandset and Dr Eivind Berge, Oslo University Hospital Ullevål, Norway, and colleagues.
The best way to manage high blood pressure in acute stroke is not known, and current practice is to accept high blood pressure in this situation. Candesartan belongs to the family of drugs called angiotensin-receptor blockers, used to lower blood pressure, and the authors studied the effects of this drug in acute stroke patients.
Patients aged 18 years and over with acute stroke and systolic blood pressure above 140 mm Hg were allocated to either candesartan (1017 patients) or placebo (1012) for 7 days. During the 7-day treatment period, blood pressures were significantly lower in patients given candesartan (147/82 mm Hg vs 152/84 in placebo group). But during 6 months’ follow-up, risk of vascular death, stroke, or heart attack did not differ significantly between the two groups. The analysis also revealed that patients given candesartan were more likely to have a poor outcome than patients given placebo, although this finding was not statistically significant. The results were the same in all pre-specified subgroups, and for all secondary endpoints. Nine patients in the candesartan group experienced symptoms due to low blood pressure versus 5 in the placebo group, and kidney failure was also more frequent in the candesartan group (18 patients) than the placebo group (13 patients). The authors also did a meta-analysis including these findings, which further confirmed the lack of beneficial effect.
The authors say: “Our results showed no beneficial effect of blood-pressure lowering treatment with the angiotensin-receptor blocker candesartan in patients with acute stroke and raised blood pressure…Other trials are ongoing, but until these trials have been completed we see no place for routine blood pressure lowering treatment in the acute phase of stroke.”
In a linked Comment, Professor Graeme J Hankey, Stroke Unit, Royal Perth Hospital and University of Western Australia, Perth, WA, Australia, says: “The results of SCAST, when added to the results of the ten previous trials of lowering of blood pressure in acute stroke, increase the reliability of the evidence and indicate that, in acute stroke, pharmacologically lowering blood pressure does not have an overall beneficial effect on functional outcome…Clinicians should therefore not be prescribing blood pressure-lowering drugs within the first week of acute stroke in routine practice.”
He adds however that it is uncertain whether other blood pressure-lowering strategies in acute stroke could have favourable effects on outcome, and like theArticle authors awaits the results of some ongoing studies to gain more evidence.
The finding in the SCASTS study,confirm my opinion that:It is not the immediate regulation
of the blood pressure that count,but the control
of the Vascular endothelium dysfunction.
As I said previously:”Vascular endothelium dysfunction is the MOTHER of all diseases in
this world”