​Blood pressure management strategies for ischemic stroke: from the acute phase to secondary prevention

*Only for medical professionals to read the reference guide and the literature hodgepodge
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Blood pressure management of stroke patients is a common clinical problem.
Improper management can cause repeated strokes and even severe acute events
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From July 9th to July 11th, at the 7th Academic Annual Meeting of the Chinese Stroke Society (CSA&TISC 2021), Professor Sun Yongan from the Department of Neurology, Peking University First Hospital discussed "Ischemia Stroke Blood Pressure Management Strategies: From the Acute Phase I gave a wonderful lecture on the topic of "Secondary Prevention", let's take a look~ The proportion of stroke patients with hypertension is as high as 84.
24%, and the treatment of hypertension is urgent! Professor Sun Yongan introduced that the cross-sectional survey of the burden of stroke disease in China hosted by the Ness-China collaborative research group shows that among stroke patients, the proportion of patients with hypertension is the highest, as high as 84.
24%
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A systematic analysis of the global burden of disease in 2013 analyzed the burden of stroke and its risk factors in 188 countries.
The results showed that hypertension ranked first in the ranking of stroke risk factors
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All these indicate that hypertension is the number one risk factor for stroke.
From the hospital to the out-of-hospital, blood pressure management for patients with ischemic stroke should be done
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Figure 1: Ranking of risk factors for stroke acute blood pressure management 1.
Intravenous thrombolysis SITS-ISTR study: With the decrease of blood pressure before thrombolysis, the patient's functional prognosis has been significantly improved
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The SITS-ISTR study enrolled 11080 patients with ischemic stroke who received intravenous thrombolysis from 403 centers in 28 countries
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Among them, patients with a history of hypertension were given antihypertensive therapy within 7 days after thrombolysis.
The researchers retrospectively analyzed the relationship between baseline blood pressure and prognosis in thrombolytic patients.
Endpoints include the incidence of short-term symptomatic intracranial hemorrhage (sICH), 3 Case fatality rate and disability rate at 1 month
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Figure 2: SITS-ISTR Study IST-3 Study: In patients with acute ischemic stroke treated with thrombolysis, antihypertensive treatment within 24 hours of onset can significantly improve the 6-month functional prognosis
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The IST-3 study included 3035 patients with acute ischemic stroke who underwent intravenous thrombolysis and evaluated the impact of early antihypertensive therapy
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The results show that the use of antihypertensive drugs within 24 hours of onset can significantly reduce the early mortality rate and improve the functional prognosis at 6 months
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Figure 3: Recommendations of the IST-3 research guidelines: 2019 AHA/ASA guidelines for early management of acute ischemic stroke: For patients with indications for intravenous alteplase thrombolysis but elevated blood pressure, they should be cautious to lower their blood pressure and increase their blood pressure before thrombolysis <185/110mmHg
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2019 Chinese cerebrovascular disease clinical management guidelines: Patients with elevated blood pressure and other aspects suitable for intravenous alteplase treatment should be cautiously lowered blood pressure before thrombolysis, so that systolic blood pressure is less than 180mmHg, and diastolic blood pressure is less than 100mmHg
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The blood pressure within 24 hours after intravenous alteplase thrombolysis should be less than 180/100mmHg
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2.
Endovascular therapy SBP and DBP are independent predictors of sICH after recanalization.
A retrospective cohort study included 674 patients with acute ischemic stroke who received continuous intravenous thrombolysis or arterial thrombolysis within 24 hours after the stroke.
The blood pressure was measured at regular intervals, and the recanalization was assessed by imaging examination 6 hours later, the 3-month prognosis was assessed by the modified Rankin scale (mRS), and the current and quadratic multiple regression models were used to analyze the relationship between blood pressure and overall patient, vascular revascularization.
Patients with successful communication and patients with vascular recanalization failure
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Figure 4: The study suggests that the higher the blood pressure, the higher the incidence of sICH.
The higher the baseline systolic blood pressure.
The occurrence of acute ischemic stroke sICH and poor prognosis.
A multicenter randomized study on endovascular treatment of acute ischemic stroke (AIS) The post-event analysis of the clinical trial included 500 AIS patients, of which 233 received arterial thrombolysis, blood pressure was measured before admission, and prognostic and safety data were observed for 3 months
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The results showed that the higher the baseline level of AlS patients before endovascular treatment, the greater the risk of sICH
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Figure 5: The relationship between systolic blood pressure and 90-day prognosis in patients with AIS undergoing arterial thrombolysis.
Guidelines Recommendation: 2019 AHA/ASA Guidelines for Early Management of Acute Ischemic Stroke: Patients who have not received intravenous thrombolysis but plan intra-arterial treatment in the new Before the emergence of the evidence, it is reasonable to control the preoperative blood pressure to be ≤185/110mmHg
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The 2018 China Guidelines for Endovascular Treatment of Acute Ischemic Stroke: Before endovascular treatment, blood pressure should be controlled below 180/105mmHg.
During mechanical thrombectomy and within 24 hours after treatment, blood pressure should be controlled within 180/105mmHg
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3.
Non-venous thrombolysis/endovascular treatment CATIS subgroup analysis: starting blood pressure at 24 to 48 hours after stroke can significantly reduce the risk of death and disability within 3 months
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According to CATIS subgroup analysis, 4071 patients with acute ischemic stroke were divided into 3 groups according to the time of blood pressure reduction (<12h after stroke, 12-23h after stroke, 24-48h after stroke) and followed up for 3 months
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The primary endpoint was a composite event of death and major disability, and the secondary endpoints were mRS score, stroke recurrence, vascular events, and death from all causes
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Figure 6: CATIS subgroup analysis COSSACS study: whether there is no significant benefit from continuing antihypertensive therapy in patients with acute stroke in the early stage.
Multicenter, prospective, randomized, open, blinded endpoint study, including 763 acute strokes (within 48 hours of onset, 58 %-67% were ischemic stroke) patients, randomized to continue or stop the antihypertensive drugs used before, followed up for 2 weeks
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Primary endpoint: death or need for help in life (defined as mRS score> 3 points at 2 weeks)
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The results of the study suggest that patients with acute stroke continue to lower blood pressure or stop blood pressure early, and have no significant effect on the primary endpoint at 2 weeks
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Figure 7: COSSACS Research Guidelines Recommendation: 2019 AHA/ASA Early Management Guidelines for Acute Ischemic Stroke: For blood pressure <220/120mmHg, no alteplase thrombolytic therapy or endovascular therapy, and no comorbidities that require emergency blood pressure reduction In treated patients, the benefit of starting or restarting antihypertensive therapy within the first 48-72h after AIS is still unclear
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2018 China Guidelines for the Diagnosis and Treatment of Acute Ischemic Stroke: For patients with stable conditions after stroke, if the blood pressure continues to be ≥140/90mmHg and there is no contraindication, antihypertensive treatment can be initiated a few days later
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2019 Chinese cerebrovascular disease clinical management guidelines: For patients with blood pressure <220/120mmHg, who have not received intravenous alteplase or intravascular therapy, and have no comorbidities requiring emergency antihypertensive treatment, start or Restarting antihypertensive therapy is not effective in preventing death or severe disability
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Secondary prevention blood pressure management PATS study: Antihypertensive treatment can significantly reduce the risk of stroke recurrence
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A randomized, double-blind, placebo-controlled trial in Chinese patients enrolled a total of 5665 patients who had a history of stroke or transient ischemic attack (TIA) and were randomized to receive antihypertensive therapy or placebo therapy
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The results suggest that antihypertensive treatment can significantly reduce the risk of stroke recurrence
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Figure 8: PATS Study Guidelines Recommendations: 2014 AHA/ASA Ischemic Stroke/TIA Secondary Prevention Guidelines: Antihypertensive therapy may be the most important intervention in the secondary prevention of ischemic stroke
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2017 Canadian Stroke Secondary Prevention Guidelines: Hypertension is the most important independently controllable risk factor for stroke.
Blood pressure monitoring and management should be carried out for all people at risk of stroke
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2014 China Guidelines for Secondary Prevention of Ischemic Stroke/TIA: Hypertension is the main risk factor for stroke and TIA
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Summary: Hypertension is the number one risk factor for stroke.
Therefore, blood pressure control is essential to reduce the risk of stroke
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For patients with acute ischemic stroke intravenous thrombolysis and endovascular treatment, blood pressure should be actively lowered.
For patients with non-venous thrombolysis/endovascular treatment, blood pressure management is still inconclusive and should be handled carefully according to individual conditions
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The secondary prevention and antihypertensive treatment of ischemic stroke is of great significance
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