Journal of the Neurological Sciences 341 (2014) 182
Contents lists available at ScienceDirect
Journal of the Neurological Sciences journal homepage: www.elsevier.com/locate/jns
Letter to the Editor Could immediate blood pressure reduction after acute ischemic stroke prevent early recurrent strokes? We read, with great interest, the JAMA article by Dr. He and his colleagues [1] suggesting that modest blood pressure (BP) reduction by 10–25% within the first 24 h after randomization and maintained at less than 140/90 mm Hg for an average hospitalization period of 13 days did not reduce the likelihood of death and major disability at 14 days or hospital discharge, compared with the absence of antihypertensive medication. The study results provide important evidence about the utility of BP management for enhancing two key outcomes in the immediate post-stroke period. While the conclusions seem appropriate, the authors do not discuss the potential impact of this BP management approach on another major early post-stroke outcome, i.e. recurrent stroke. Approximately one-quarter of all strokes are recurrent strokes [2], and the period of highest risk for recurrence is within the first 3 months post stroke [3]. Indeed, the authors neglected to point out that there was actually a strong trend towards modest benefit in favor of the treatment group, amounting to a 35% relative risk reduction in stroke recurrence at 3 months. Since there was only a clinically negligible difference in mean systolic blood pressure between two groups at 3 months {−2.7 mm Hg (−3.7 to −2.2)}, it would be reasonable to postulate that this benefit likely came from the initial BP reduction (9.3 mm Hg difference at day 7). This trend towards recurrent stroke benefit was not observed in another clinical trial of early BP reduction in acute stroke where the BP difference at day 7 was only 4.9 mm Hg [4]. We think the results of this study, could be seen as hypothesis-generating, begging the question as to whether more aggressive BP reduction in the first 14 days after an acute stroke aiming for a SBP reduction of at least ~10 mm Hg [5] may
http://dx.doi.org/10.1016/j.jns.2014.03.036 0022-510X/© 2014 Elsevier B.V. All rights reserved.
lead to prevention of recurrent strokes at 3 months? Given the more subtle effects of stroke than death and major disability, which include modest disability, cognitive decline, and depression among others, there may be a role for a future clinical trial to test this hypothesis.
References [1] He J, Zhang Y, Xu T, et al. Effects of immediate blood pressure reduction on death and major disability in patients with acute ischemic stroke: the CATIS randomized clinical trial. JAMA 2014;311(5):479–89. [2] Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics—2013 update: a report from the American Heart Association. Circulation 2013;127(1): e6-245. [3] Coull AJ, Lovett JK, Rothwell PM. Population based study of early risk of stroke after transient ischaemic attack or minor stroke: implications for public education and organisation of services. BMJ Feb 7 2004;328(7435):326. [4] Sandset EC, Bath PM, Boysen G, et al. The angiotensin-receptor blocker candesartan for treatment of acute stroke (SCAST): a randomised, placebo-controlled, doubleblind trial. Lancet 2011;377(9767):741–50. [5] Furie KL, Kasner SE, Adams RJ, et al. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke Jan 2011;42(1):227–76.
Wuwei (Wayne) Feng Department of Neuroscience, MUSC Stroke Center, Medical University of South Carolina, Charleston, SC 29425, United States Corresponding author at: 19 Hagood Avenue, HOT-501, MUSC Stroke Center, Charleston, SC 29425, United States. Tel.: + 1 843 792 3020; fax: + 1 843 792 2484. E-mail address: [email protected]. Bruce Ovbiagele 16 March 2014
Contents lists available at ScienceDirect
Journal of the Neurological Sciences journal homepage: www.elsevier.com/locate/jns
Letter to the Editor Could immediate blood pressure reduction after acute ischemic stroke prevent early recurrent strokes? We read, with great interest, the JAMA article by Dr. He and his colleagues [1] suggesting that modest blood pressure (BP) reduction by 10–25% within the first 24 h after randomization and maintained at less than 140/90 mm Hg for an average hospitalization period of 13 days did not reduce the likelihood of death and major disability at 14 days or hospital discharge, compared with the absence of antihypertensive medication. The study results provide important evidence about the utility of BP management for enhancing two key outcomes in the immediate post-stroke period. While the conclusions seem appropriate, the authors do not discuss the potential impact of this BP management approach on another major early post-stroke outcome, i.e. recurrent stroke. Approximately one-quarter of all strokes are recurrent strokes [2], and the period of highest risk for recurrence is within the first 3 months post stroke [3]. Indeed, the authors neglected to point out that there was actually a strong trend towards modest benefit in favor of the treatment group, amounting to a 35% relative risk reduction in stroke recurrence at 3 months. Since there was only a clinically negligible difference in mean systolic blood pressure between two groups at 3 months {−2.7 mm Hg (−3.7 to −2.2)}, it would be reasonable to postulate that this benefit likely came from the initial BP reduction (9.3 mm Hg difference at day 7). This trend towards recurrent stroke benefit was not observed in another clinical trial of early BP reduction in acute stroke where the BP difference at day 7 was only 4.9 mm Hg [4]. We think the results of this study, could be seen as hypothesis-generating, begging the question as to whether more aggressive BP reduction in the first 14 days after an acute stroke aiming for a SBP reduction of at least ~10 mm Hg [5] may
http://dx.doi.org/10.1016/j.jns.2014.03.036 0022-510X/© 2014 Elsevier B.V. All rights reserved.
lead to prevention of recurrent strokes at 3 months? Given the more subtle effects of stroke than death and major disability, which include modest disability, cognitive decline, and depression among others, there may be a role for a future clinical trial to test this hypothesis.
References [1] He J, Zhang Y, Xu T, et al. Effects of immediate blood pressure reduction on death and major disability in patients with acute ischemic stroke: the CATIS randomized clinical trial. JAMA 2014;311(5):479–89. [2] Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics—2013 update: a report from the American Heart Association. Circulation 2013;127(1): e6-245. [3] Coull AJ, Lovett JK, Rothwell PM. Population based study of early risk of stroke after transient ischaemic attack or minor stroke: implications for public education and organisation of services. BMJ Feb 7 2004;328(7435):326. [4] Sandset EC, Bath PM, Boysen G, et al. The angiotensin-receptor blocker candesartan for treatment of acute stroke (SCAST): a randomised, placebo-controlled, doubleblind trial. Lancet 2011;377(9767):741–50. [5] Furie KL, Kasner SE, Adams RJ, et al. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke Jan 2011;42(1):227–76.
Wuwei (Wayne) Feng Department of Neuroscience, MUSC Stroke Center, Medical University of South Carolina, Charleston, SC 29425, United States Corresponding author at: 19 Hagood Avenue, HOT-501, MUSC Stroke Center, Charleston, SC 29425, United States. Tel.: + 1 843 792 3020; fax: + 1 843 792 2484. E-mail address: [email protected]. Bruce Ovbiagele 16 March 2014
