An ARB for Hypertensive Patients with Acute Stroke?

In patients with acute ischemic stroke, guidelines recommend withholding antihypertensive treatment until systolic blood pressure exceeds 220 mm Hg or diastolic BP exceeds 120 mm Hg (Stroke 2007; 38:1655). A slightly lower threshold (180–200 mm Hg) is recommended in patients with hemorrhagic stroke (Stroke 2010; 41:2108). However, hard evidence is lacking to support any particular threshold.

In this randomized European trial, 2000 patients with acute stroke (86% ischemic; 14% hemorrhagic) and systolic BP >140 mm Hg received 7-day courses of either placebo or the angiotensin-receptor blocker candesartan (Atacand; dose titrated to 16 mg, if necessary). Mean BP at enrollment was 171/90 mm Hg; during treatment, mean systolic BP averaged 3 to 5 mm Hg lower with candesartan than with placebo.

During the 7-day treatment phase, neurological status (according to a standardized stroke scale) was similar in the candesartan and placebo groups, but 6-month functional status was marginally worse in the candesartan group (P=0.05). At 6 months, a primary composite vascular endpoint (stroke, myocardial infarction, vascular death) had occurred with similar frequency in the two groups. Candesartan therapy did not benefit patients with the highest baseline systolic BPs (i.e., >180 or >200 mm Hg) or patients with hemorrhagic strokes.