Type A, Race, Anger, Forgiveness, Plus Stroke, HRT, and Hydralazine - The Bad, the Good, and the To-Be-Avoided

November 14, 2003

In This Article

Blood Pressure Reduction Detrimental in First 24 Hours After Stroke Onset

New data supporting the current guideline position that blood pressure reduction in the acute stroke setting should be avoided if possible come from Brazilian researchers, published in the October issue of Neurology.[14] Jamary Oliveira-Filho, MD (Federal University of Bahia) and colleagues prospectively studied 115 consecutive patients admitted to a major urban hospital in the first 24 hours of stroke onset. Most patients were elderly men with a mean NIH Stroke Scale (NIHSS) score of 4.5. The main stroke etiology was cardioembolism (30%). All patients had a blood pressure reduction within 24 h, either spontaneously or due to antihypertensive medication. After 3 months, 44 (39%) patients had a poor outcome, as defined by a Rankin score > 2 or a Barthel score < 70. Predictors of poor outcome, by univariable analysis, were older age, higher NIHSS score, higher body temperature over the first 24 h, total anterior circulation strokes, nonlacunar strokes, lack of antiplatelet use in the first 24 h, lower DBP on admission, and a larger decrease over the first 24 h. After multivariable analysis, the only variables that remained significant predictors of poor outcome were NIHSS score and the degree of SBP reduction. The risk of poor outcome was increased almost 2-fold for every 10% decrease in SBP over the first 24 h. Outcome was unaffected by antihypertensive medication use.

In an accompanying editorial,[15] Karen C Johnston, MD (University of Virginia, Charlottesville) and Stephan Mayer, MD (Columbia University, New York) note that, despite limitations, the Brazilian study "supports anecdotal literature and is of interest and importance." They stress the urgency of determining the optimal management of blood pressure in patients with acute stroke. In the absence of a definitive, well-designed randomized trial, they suggest that if blood pressure is to be lowered in the first 24 h after stroke, it should be lowered "carefully and in a monitored setting with an easily titratable, short-acting agent such as labetalol or nicardipine."


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