Diagnosis required for early blood pressure control benefit in acute stroke - EMJ

Diagnosis Required for Early Blood Pressure Control Benefit in Acute Stroke

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EARLY in-ambulance administration of blood pressure treatment is not associated with improved functional outcomes in patients with undifferentiated acute stroke. The decision of healthcare professionals on the treatment of acute stroke is challenging before a diagnosis of ischemic and haemorrhagic types is made. Moreover, there is insufficient data supporting whether in-ambulance early blood-pressure control improves outcomes in undifferentiated acute stroke. Therefore, researchers conducted a study investigating the impact of early ambulance-delivered blood pressure reduction on acute stroke outcomes.  

Researchers conducted the intensive ambulance-delivered blood pressure reduction in a hyper-acute stroke trial to assess acute stroke outcomes. This double-blind, open-label multicentre study utilised ambulance-assessed patients from dozens of ambulance services in China. Suspected acute stroke patients with motor deficits and elevated systolic blood pressure (≥150mmHg) were assessed within two hours of onset. Following assessment, patients were randomly assigned to receive immediate treatment to lower systolic or usual in-hospital blood pressure management. Randomisation comprised 2,404 patients: 1205 in the intervention group and 1,199 in the in-hospital blood management group. The primary objective of the study was to assess functional status 90 days after randomisation by employing the modified Rankin scale (range, 0 [no symptoms] to 6 [death]).   

Stroke was confirmed in 2,240 patients through CT imaging: 1,041 (46.5%) had a haemorrhagic stroke, while the remainder had ischaemic stroke. Functional outcomes of patients in the intervention and hospital care groups with the same type of acute stroke were compared. Results revealed that intervention group patients with intracerebral haemorrhage and prehospital reduction in blood pressure had a 30% decreased likelihood of poor functional outcomes (common odds ratio, 0.75; 95% confidence interval [CI], 0.60 to 0.92). However, intervention group patients with cerebral ischemia had worsened outcomes with an equivalent 30% higher likelihood of worse outcomes. Therefore, the impact of prehospital blood pressure reduction due to early intervention had no overall difference in the functional outcomes of acute stroke patients.   

The authors concluded that the findings do not support the blanket use of early blood pressure control in ambulances; instead, a reliable diagnosis of ischemic and haemorrhage acute stroke is required to maximise the benefit of early blood pressure intervention. Furthermore, an increasing number of stroke ambulances are equipped with diagnostic tools, such as CT scanners, that enable the early identification of ischaemic stroke and, thus, the administration of clot-busting treatment. Nevertheless, faster diagnosis and swifter action in emergency departments are pivotal in preserving brain function. 



Li, G et al, Intensive ambulance-delivered blood-pressure reduction in hyperacute stroke. New England Journal of Medicine. 

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