Treating hypertension after stroke

Interventions for deliberately altering blood pressure in acute stroke

BACKGROUND

It is unclear whether blood pressure should be altered actively during the acute phase of stroke. This is an update of a Cochrane review first published in 1997, and previously updated in 2001 and 2008.

OBJECTIVES

To assess the clinical effectiveness of altering blood pressure in people with acute stroke, and the effect of different vasoactive drugs on blood pressure in acute stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched in February 2014), the Cochrane Database of Systematic reviews (CDSR) and the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 2), MEDLINE (Ovid) (1966 to May 2014), EMBASE (Ovid) (1974 to May 2014), Science Citation Index (ISI, Web of Science, 1981 to May 2014) and the Stroke Trials Registry (searched May 2014).

SELECTION CRITERIA

Randomised controlled trials of interventions that aimed to alter blood pressure compared with control in participants within one week of acute ischaemic or haemorrhagic stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently applied the inclusion criteria, assessed trial quality and extracted data. The review authors cross-checked data and resolved discrepancies by discussion to reach consensus. We obtained published and unpublished data where available.

MAIN RESULTS

We included 26 trials involving 17,011 participants (8497 participants were assigned active therapy and 8514 participants received placebo/control). Not all trials contributed to each outcome. Most data came from trials that had a wide time window for recruitment; four trials gave treatment within six hours and one trial within eight hours. The trials tested alpha-2 adrenergic agonists (A2AA), angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor antagonists (ARA), calcium channel blockers (CCBs), nitric oxide (NO) donors, thiazide-like diuretics, and target-driven blood pressure lowering. One trial tested phenylephrine.At 24 hours after randomisation oral ACEIs reduced systolic blood pressure (SBP, mean difference (MD) -8 mmHg, 95% confidence interval (CI) -17 to 1) and diastolic blood pressure (DBP, MD -3 mmHg, 95% CI -9 to 2), sublingual ACEIs reduced SBP (MD -12.00 mm Hg, 95% CI -26 to 2) and DBP (MD -2, 95%CI -10 to 6), oral ARA reduced SBP (MD -1 mm Hg, 95% CI -3 to 2) and DBP (MD -1 mm Hg, 95% CI -3 to 1), oral beta blockers reduced SBP (MD -14 mm Hg; 95% CI -27 to -1) and DBP (MD -1 mm Hg, 95% CI -9 to 7), intravenous (iv) beta blockers reduced SBP (MD -5 mm Hg, 95% CI -18 to 8) and DBP (-5 mm Hg, 95% CI -13 to 3), oral CCBs reduced SBP (MD -13 mmHg, 95% CI -43 to 17) and DBP (MD -6 mmHg, 95% CI -14 to 2), iv CCBs reduced SBP (MD -32 mmHg, 95% CI -65 to 1) and DBP (MD -13, 95% CI -31 to 6), NO donors reduced SBP (MD -12 mmHg, 95% CI -19 to -5) and DBP (MD -3, 95% CI -4 to -2) while phenylephrine, non-significantly increased SBP (MD 21 mmHg, 95% CI -13 to 55) and DBP (MD 1 mmHg, 95% CI -15 to 16).Blood pressure lowering did not reduce death or dependency either by drug class (OR 0.98, 95% CI 0.92 to 1.05), stroke type (OR 0.98, 95% CI 0.92 to 1.05) or time to treatment (OR 0.98, 95% CI 0.92 to 1.05). Treatment within six hours of stroke appeared effective in reducing death or dependency (OR 0.86, 95% CI 0.76 to 0.99) but not death (OR 0.70, 95% CI 0.38 to 1.26) at the end of the trial. Although death or dependency did not differ between people who continued pre-stroke antihypertensive treatment versus those who stopped it temporarily (worse outcome with continuing treatment, OR 1.06, 95% CI 0.91 to 1.24), disability scores at the end of the trial were worse in participants randomised to continue treatment (Barthel Index, MD -3.2, 95% CI -5.8, -0.6).

AUTHORS' CONCLUSIONS

There is insufficient evidence that lowering blood pressure during the acute phase of stroke improves functional outcome. It is reasonable to withhold blood pressure-lowering drugs until patients are medically and neurologically stable, and have suitable oral or enteral access, after which drugs can than be reintroduced. In people with acute stroke, CCBs, ACEI, ARA, beta blockers and NO donors each lower blood pressure while phenylephrine probably increases blood pressure. Further trials are needed to identify which people are most likely to benefit from early treatment, in particular whether treatment started very early is beneficial.

Anaesthesia for caesarean delivery in a parturient following a recent cerebrovascular event

Ischaemic cerebrovascular events in pregnancy are uncommon. The anaesthetic management of a pregnant patient within six weeks of an ischaemic cerebrovascular event has not previously been reported. Issues raised include consent and minimising further neurological insult. Changes in regional blood flow, cerebral metabolic rate and integrity of the blood brain barrier must be considered although evidence to support regional in preference to general anaesthesia is lacking. We report the case of a woman with known systemic lupus erythematosis and antiphospholipid syndrome who developed idiopathic thrombocytopenic purpura in pregnancy and suffered a thrombotic cerebral vascular accident at 32 weeks of gestation. Ten days later she required urgent caesarean delivery, which was performed under general anaesthesia. There was no deterioration in neurological function following surgery and eight days postoperatively she was transferred to a neuro-rehabilitation centre for further care. The idiopathic thrombocytopenic purpura did not respond to medical therapy following delivery and a second anaesthetic was required for splenectomy four weeks later.

Interventions for deliberately altering blood pressure in acute stroke

BACKGROUND

It is unclear whether blood pressure should be altered actively during the acute phase of stroke. This is an update of a Cochrane review first published in 1997, and previously updated in 2001.

OBJECTIVES

To assess the effect of altering blood pressure in people with acute stroke, and the effect of different vasoactive drugs on blood pressure in acute stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched July 2007), the Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2 2008), MEDLINE, EMBASE and other databases, reference lists of relevant publications and contacted researchers in the field.

SELECTION CRITERIA

Randomised controlled trials of interventions that aimed to alter blood pressure in patients within one week of acute ischaemic or haemorrhagic stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently applied the inclusion criteria, assessed trial quality and extracted data.

MAIN RESULTS

Twelve trials involving 1153 participants were included (603 participants were assigned active therapy and 550 participants received placebo/control). The trials tested angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor antagonists (ARA), calcium channel blockers (CCBs), clonidine, glyceryl trinitrate (GTN), thiazide diuretic and mixed antihypertensive therapy. One trial tested phenylephrine. At 24 hours after randomisation ACEIs reduced systolic blood pressure (SBP, mean difference, MD -6 mmHg, 95% confidence interval, CI -22 to 10) and diastolic blood pressure (DBP, MD -5 mmHg, 95% CI -18 to 7), ARA reduced SBP (MD -3, 95% CI -7 to 2) and DBP (MD -3, 95% CI -6 to 0.4), iv CCBs reduced SBP (MD -32 mmHg, 95% CI -65 to 1) and DBP (MD -13 mmHg, 95% CI -31 to 6), oral CCBs reduced SBP (MD -13 mmHg, 95% , CI -43 to 17) and DBP (MD -6 mmHg, 95% CI -14 to 2), GTN reduced SBP (MD -10 mmHg, 95% CI -18 to -3) and DBP (MD -1 mmHg, 95% CI -5 to 3) while phenylephrine, non-significantly increased SBP (MD 21 mmHg, 95% CI -13 to 55) and DBP (MD 1 mmHg, 95% CI -15 to 16). Functional outcome and death were not altered by any of the drugs.

AUTHORS' CONCLUSIONS

There is insufficient evidence to evaluate the effect of altering blood pressure on outcome during the acute phase of stroke. In patients with acute stroke, CCBs, ACEI, ARA and GTN each lower blood pressure while phenylephrine probably increases blood pressure.

Hypertensive crises: challenges and management

Hypertension affects > 65 million people in the United States and is one of the leading causes of death. One to two percent of patients with hypertension have acute elevations of BP that require urgent medical treatment. Depending on the degree of BP elevation and presence of end-organ damage, severe hypertension can be defined as either a hypertensive emergency or a hypertensive urgency. A hypertensive emergency is associated with acute end-organ damage and requires immediate treatment with a titratable short-acting IV antihypertensive agent. Severe hypertension without acute end-organ damage is referred to as a hypertensive urgency and is usually treated with oral antihypertensive agents. This article reviews definitions, current concepts, common misconceptions, and pitfalls in the diagnosis and management of patients with acutely elevated BP as well as special clinical situations in which BP must be controlled.

Current diagnosis and management of hypertensive emergency

The appropriate and timely evaluation and treatment of patients with severely elevated blood pressure is essential to avoid serious adverse outcomes. Most importantly, the distinction between a hypertensive emergency (crisis) and urgency needs to be made. A sudden elevation in systolic (SBP) and/or diastolic blood pressure (DBP) that is associated with acute end organ damage (cardiovascular, cerebrovascular, or renal) is defined as a hypertensive crisis or emergency. In contrast, acute elevation in SBP and/or DBP not associated with evidence of end organ damage is defined as hypertensive urgency. In patients with a hypertensive emergency, blood pressure control should be attained as expeditiously as possible with parenteral medications to prevent ongoing and potentially permanent end organ damage. In contrast, with hypertensive urgency, blood pressure control can be achieved with the use of oral medications within 24-48 hours. This paper reviews the management of hypertensive emergencies.

Hemodynamic disturbances associated with endovascular embolization in newborn infants with vein of Galen malformation

OBJECTIVE

To examine hemodynamic changes following endovascular embolization in newborn infants with vein of Galen malformation and severe cardiac failure in the first week of life.

STUDY DESIGN

Over a recent 5-year period, nine such infants were identified. In seven of these infants, changes in arterial blood pressure were analyzed in relation to the timing of embolization procedures.

RESULTS

A significant increase in arterial blood pressure was noted after most embolizations. In two infants, this systemic hypertension was severe and treated using intravenous antihypertensive drugs. Both infants subsequently developed complete infarction of both cerebral hemispheres with sparing of the brainstem and cerebellum. Mortality in the nine infants was 33%, and 83% of the survivors were neurologically normal or near normal at follow-up.

CONCLUSION

The systemic hypertension observed following endovascular embolizations may provide a protective mechanism to maintain cerebral blood flow after reperfusion injury. Lowering blood pressure in this situation may therefore be detrimental.

Blood pressure, nimodipine, and outcome of ischemic stroke

OBJECTIVES

The reduction of blood pressure (BP) caused by nimodipine has been proposed as an explanation for the poor results in ischemic stroke trials. We evaluated further the relationships between BP, nimodipine, and outcome of ischemic stroke, and also searched for other possible explaining mechanisms.

PATIENTS AND METHODS

All 350 participants of an earlier placebo controlled trial on oral nimodipine were included in this study. Among other variables, the admission BP, and the change of BP during the first day were noted. The 3 week and 3 month functional outcome was assessed with a modified Rankin grading.

RESULTS

The severity of stroke was the utmost important predictor of outcome. Visible cerebral infarction on computed tomography (CT) was associated with severe stroke and an early commencement (within 24 h of stroke onset) of nimodipine treatment. In the nimodipine arm, high initial systolic and diastolic BP measured < or =24 h of stroke onset were independent predictors of good functional outcome (Rankin grades 1 and 2), whereas BP change was not. The survivors in the nimodipine arm with mild to moderately severe stroke had higher initial BP than the deceased ones, in severe strokes the situation was the opposite.

CONCLUSIONS

Stroke severity, visible cerebral infarcts on CT, and early commencement of nimodipine treatment were associated. Overall, high initial systolic and diastolic BP predicted a good functional outcome in patients on nimodipine. In severe strokes, the combination of nimodipine and high initial BP was associated with increased risk of death.

Clinical review: the management of hypertensive crises

Hypertension is an extremely common clinical problem, affecting approximately 50 million people in the USA and approximately 1 billion individuals worldwide. Approximately 1% of these patients will develop acute elevations in blood pressure at some point in their lifetime. A number of terms have been applied to severe hypertension, including hypertensive crises, emergencies, and urgencies. By definition, acute elevations in blood pressure that are associated with end-organ damage are called hypertensive crises. Immediate reduction in blood pressure is required only in patients with acute end-organ damage. This article reviews current concepts, and common misconceptions and pitfalls in the diagnosis and management of patients with acutely elevated blood pressure.

Variation in the management of acute physiological parameters after ischaemic stroke: a European perspective

Studies have shown significant variation in stroke case fatality across Europe. These variations suggest the need to explore whether differences in physiological support in acute stroke exist across Europe. Data were collected in four European centres over 6 months. These included clinical status and management of acute physiology (hydration, oxygenation, nutrition, hypertension, hyperglycaemia and temperature in the first week of ischaemic stroke) and survival at 3 months. Differences in acute supportive care between centres were adjusted for case mix. Patients admitted to centres in London (n = 106), Dijon (n = 95), Erlangen (n = 91) and Warsaw (n = 72) were studied. There were significant differences in incontinence, dysphasia, dysphagia, conscious level, pyrexia, hyperglycaemia and comorbidity between centres. After adjusting for case mix, there were significant differences in intravenous fluid use (P = 0.04), enteral feeding (P = 0.003), initiation of new antihypertensive therapy (P = 0.0006) and insulin therapy (P = 0.004) between centres, with the London centre having the lowest uptake of interventions. Three-month case fatality rates varied from 10 to 28%. This pilot study shows significant variation in acute physiological support in acute stroke across four European centres, which remains unexplained by case mix. Further research is required to link variation in acute care with stroke outcome, to identify which interventions appear to be the most effective.

Twenty-four hour systolic blood pressure predicts long-term mortality following acute stroke

OBJECTIVE

To assess the effects of acute blood pressure (BP) on long-term mortality following stroke.

DESIGN

Prospective observational study.

SETTING

Leicester Teaching Hospitals.

PATIENTS

Two hundred and nineteen consecutive patients were recruited within 24 h of acute stroke.

INTERVENTIONS

Clinic and 24 h BP levels were measured. Other risk factors previously associated with stroke mortality were recorded within 24 h of admission. No specific pharmacological interventions;were made.

MAIN OUTCOME MEASURES

The primary outcome measure was death over a median follow-up period of over 2.5 years. The hazards ratios associated with predefined variables were assessed using Cox's proportional hazards modelling, and Kaplan-Meier survival plots were also calculated.

RESULTS

On multiple variable analysis, 24 h systolic BP (> or = 160 mmHg) was associated with an increased hazards ratio of 2.41 (95% confidence intervals: 1.24-4.67) for death, compared to the reference group (140-159 mmHg). The addition of 24 h heart rate was significant, with increasing heart rate (> 83 bpm) associated with an increased mortality (P = 0.006), although this effect was not constant over time. Increasing age (> 80 years) at presentation was also associated with an increased hazards ratio of 2.53 (1.14-5.62) compared to age < or = 66 years.

CONCLUSIONS

This study provides evidence that elevated 24 h systolic BP in the acute stroke period is associated with increased long-term mortality. This may have implications in the therapeutic management of BP following stroke, though further research is required to determine the timing, nature and effect of such an intervention.

The effect of 24 h blood pressure levels on early neurological recovery after stroke

OBJECTIVES

To assess the influence of 24 h blood pressure (BP) levels on functional recovery 1 week after stroke and the effect of antihypertensive therapy on 24 h BP levels.

DESIGN

Prospective study of patients admitted to hospital over 1 year with first in a lifetime stroke who underwent 24 h BP and casual measurements. Setting. Medical wards in a teaching hospital. Subjects. Of 160 patients, 72 patients admitted to hospital within 24 h of stroke onset were investigated. Patients with conditions and therapy that interfered with autonomic and sympathetic function were excluded. Interventions. All subjects underwent 24 h BP and casual recordings on admission to hospital and at day seven after stroke. The mean 24 h, day and night systolic BP (SBP) and diastolic BP (DBP) and their differences (nocturnal BP dip) were recorded. Patients were divided into three groups according to whether they were taking antihypertensive therapy during the first week: (i) no therapy, (ii) therapy continued after stroke, and (iii) new therapy introduced. Main outcome measures. Functional recovery (Rankin Scale 0-1) and neurological improvement [Scandinavian Stroke Scale (SSS) >/=3 points] by 1 week of stroke. Change in circadian 24 h BP over 1 week.

RESULTS

For each 10 mmHg difference between day and night time DBP, the odds for making a complete recovery were 4.63 (95% CI: 1.57-13.7, P=0.01). For each 10 mmHg difference between day and night SBP, the odds for making an improvement in neurological status was 2.24 (95% CI: 1.16-4.32; P=0.016). Significant falls in 24 h DBP (P=0.01), daytime SBP (P=0.005) and mean arterial BP (MABP) (P=0.04) over 1 week were demonstrated in patients who had just commenced antihypertensive therapy (P=0.001).

CONCLUSION

An increase in day to night time BP change is favourable in short-term outcome after acute stroke. Significant falls in BP are more likely in patients started on antihypertensive therapy for the first time. Further research is required to understand the effects of circadian BP rhythm on stroke outcome.

Hypertension in patients presenting with stroke

Hypertension is a major risk factor for stroke disease. There is now some international agreement on what constitutes hypertension, and at what level of blood pressure treatment is required. Large randomised controlled trials demonstrate the benefit of reducing blood pressure for the primary and secondary prevention of stroke disease. Studies have also demonstrated the benefit of particular classes of antihypertensive agents in certain patient groups. Research is beginning to elucidate the problems of hypertension in the acute phase of ischaemic stroke and the therapeutic strategies that may be helpful. Given the significant impact of stroke disease on all health services, it remains an important priority to determine the best management of hypertension in stroke.

The diagnosis and management of hypertensive crises

Severe hypertension is a common clinical problem in the United States, encountered in various clinical settings. Although various terms have been applied to severe hypertension, such as hypertensive crises, emergencies, or urgencies, they are all characterized by acute elevations in BP that may be associated with end-organ damage (hypertensive crisis). The immediate reduction of BP is only required in patients with acute end-organ damage. Hypertension associated with cerebral infarction or intracerebral hemorrhage only rarely requires treatment. While nitroprusside is commonly used to treat severe hypertension, it is an extremely toxic drug that should only be used in rare circumstances. Furthermore, the short-acting calcium channel blocker nifedipine is associated with significant morbidity and should be avoided. Today, a wide range of pharmacologic alternatives are available to the practitioner to control severe hypertension. This article reviews some of the current concepts and common misconceptions in the management of patients with acutely elevated BP.

Vasoactive drugs for acute stroke

BACKGROUND

It is unclear whether blood pressure should be managed after acute stroke and if so whether it is best to reduce or increase blood pressure.

OBJECTIVES

The objective of this review was to assess the effect of lowering or elevating blood pressure in people with acute stroke, and the effect of different vasoactive drugs on blood pressure in acute stroke.

SEARCH STRATEGY

We searched the Cochrane Library (1999 Issue 1) using the CDSR and the CCTR databases, MEDLINE (from 1966), EMBASE (from 1980), BIDS ISI (Science Citation Index from 1981), and existing review articles. We contacted researchers in the field and pharmaceutical companies.

SELECTION CRITERIA

Randomised trials of interventions that would be expected, on pharmacological grounds, to alter blood pressure in patients within two weeks of the onset of acute ischaemic or haemorrhagic stroke.

DATA COLLECTION AND ANALYSIS

Two reviewers independently applied the trial inclusion criteria, assessed trial quality, and extracted the data.

MAIN RESULTS

Sixty five trials were identified involving in excess of 11,500 patients; a further 5 trials are ongoing. Data were obtained for 32 trials (5,368 patients). Significant imbalances in baseline blood pressure were present across trials of intravenous calcium channel blockers and prostacyclin. Major imbalances in baseline blood pressure between treatment and control groups have made the interpretation of these results difficult. Intravenous calcium channel blockers (CCBs) and oral CCBs significantly lowered late blood pressure as compared to controls. (systolic/diastolic BP): iv CCBs -8.2/-6.7 mm Hg (95% CI -12.6 to -3.8)/ (95% CI -9.2 to -4.3); oral CCBs -3.2/-2.1 mm Hg (95% CI -5.0 to -1.3)/ (95% CI -3.0 to -1.0). Beta blockers significantly lowered late diastolic blood pressure but not significantly late systolic blood pressure; -5.0/-4.5 mm Hg (95% CI -10.2 to 0.4)/(95% CI -7.8 to -1.15). Angiotensin converting enzyme inhibitors and prostacyclin non-significantly reduced late BP as compared to the controls by -5.4/-3.0 mm Hg (95% CI -16.5 to 5.8)/(95% CI -11.1 to 5.0) and -7.4/-3.9 mmHg (95% CI -15.6 to 0.2)/(95% CI -8.1 to 0.4) respectively. Magnesium, naftidrofuryl and piracetam had no significant effect on blood pressure. Oral CCBs and beta blockers each significantly reduced late heart rate (beats per minute (bpm)): CCBs -2.8 bpm (95%CI -3.9 to -1.7); beta blockers -9.3 bpm (95% CI -12.0 to -6.6). Prostacyclin significantly increased late heart rate by +5.6 bpm (95% CI 0.8 to 10.4). None of the drug classes significantly altered outcome apart from beta blockers and streptokinase which increased early case fatality (odds ratio 1.77, 95%CI, 1.05 to 3.00) and 2.27 (95% CI 1.4 to 3.67).

REVIEWER'S CONCLUSIONS

There is not enough evidence reliably to evaluate the effect of altering blood pressure on outcome after acute stroke. CCBs, beta blockers, and probably ACE-inhibitors, prostacyclin and nitric oxide, each lowered BP during the acute phase of stroke. In contrast, magnesium, naftidrofuryl and piracetam had little or no effect on BP.

Interventions for deliberately altering blood pressure in acute stroke

BACKGROUND

It is unclear whether hypertension should be treated after acute stroke, and some have hypothesised that blood pressure should be increased to improve cerebral perfusion.

OBJECTIVES

The objective of this review was to assess the effect of lowering or elevating blood pressure in people with acute stroke, and the effect of different vasoactive drugs on blood pressure in acute stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group trials register, the Ottawa Stroke Trials Registry (1994), Medline (from 1965), Embase (from 1981), ISI, and existing review articles. We contacted researchers in the field and pharmaceutical companies.

SELECTION CRITERIA

Randomised trials of interventions that aimed to alter blood pressure in patients within two weeks of acute ischaemic or haemorrhagic stroke.

DATA COLLECTION AND ANALYSIS

Two reviewers independently applied the inclusion criteria and assessed trial quality. Two reviewers extracted the data.

MAIN RESULTS

Three trials involving 133 people were included. The trials tested the following vasodilators: nimodipine (66 people), nicardipine (five people), captopril (three people) and clonidine (two people). Oral calcium channel blockers (nimodipine, nicardipine) reduced systolic blood pressure (weighted mean difference 10.9mmHg, 95% confidence interval 2.0 to 19.7), diastolic blood pressure (weighted mean difference 9.5mmHg, 95% confidence interval 4.0 to 15.1) and heart rate (weighted mean difference 4.7 beats per minute, 95% confidence interval 0.2 to 9.2) at 48 hours. The greatest fall in blood pressure over the first 24 hours was shown in patients given the highest dose of nimodipine. The relationship between change in blood pressure and clinical outcome was not clear. There was not enough information to assess the effect of drugs other than calcium channel blockers. No studies of interventions to raise blood pressure were found.

REVIEWER'S CONCLUSIONS

There is not enough evidence to evaluate the effect of altering blood pressure after acute stroke. Although oral calcium channel blockers appear to reduce blood pressure following acute stroke, the balance of benefit and risk remains unclear.

Neuroprotection in acute ischaemic stroke. II: Clinical potential

In the 4 years since our first article, there has been considerable progress in our understanding of the pathophysiology of acute ischaemic stroke, and the results of well-conducted trials have at last begun to change everyday clinical practice. The timing of the various processes of the ischaemic cascade and the potential time windows for different interventions are better understood. Furthermore, the importance of maintaining cerebral perfusion and optimizing systemic physiological and biochemical factors in order to prevent neurological deterioration ('progressing stroke') is increasingly being realized. Numerous antithrombotic and neuroprotective drugs have been evaluated in clinical trials, and while none has shown unequivocal benefits on its own, prospects for successful intervention are still good. This will probably involve different combinations of treatments targeted on different pathophysiological stroke types, so that the management of acute stroke will offer a considerable challenge to the stroke physicians of the future.

Opinion of New Zealand physicians on management of acute ischaemic stroke: results of a national survey

BACKGROUND

Randomised trials have evaluated various treatments for acute ischaemic stroke, but it is unclear how the results of these studies are used in everyday practice.

AIMS

To obtain the opinions of physicians on the management of acute ischaemic stroke.

METHODS

A questionnaire was sent to 368 New Zealand Fellows of the Royal Australasian College of Physicians. The survey included questions about the availability of hospital services for stroke patients, management of acute ischaemic stroke and opinion on the efficacy of treatments used in acute ischaemic stroke.

RESULTS

Of the 293 physicians who responded to the questionnaire, 171 managed patients in the first week after stroke. Forty-seven per cent of these physicians were general physicians. Ninety-five per cent usually managed these patients in a general medical ward. Only five physicians admitted patients to an acute stroke unit and only 57% considered acute stroke units were beneficial. Aspirin was usually or sometimes used for patients with acute ischaemic stroke by 92% of physicians, intravenous heparin by 43%, low-dose subcutaneous heparin by 41%, low-molecular-weight heparin by 25% and tissue-plasminogen activator (t-PA) by 3%. Two thirds considered that aspirin was definitely beneficial, but most were uncertain about the efficacy of intravenous heparin, low-dose subcutaneous heparin, low-molecular-weight heparin and t-PA. Sixty-two per cent were prepared to begin aspirin and 21% subcutaneous heparin before computerised tomography (CT). Twenty-three per cent used anti-hypertensive treatment in the first few hours after an ischaemic stroke.

CONCLUSIONS

Several common deficiencies in the management of acute ischaemic stroke were identified. The widespread lack of stroke units, use of aspirin and heparin before CT, and lowering of blood pressure after an acute ischaemic stroke differed from accepted guidelines. Many physicians used heparin despite lack of evidence from randomised trials that it is beneficial. The development of stroke units and the appointment of physicians with a special interest in the management of stroke may improve the management of patients with acute stroke.

Treatment of post-stroke hypertension. A practical guide

Cerebrovascular disease is a common cause of morbidity and mortality, especially in the elderly. Treatment of hypertension is effective in the primary prevention of stroke. Hypertension is seen in 80% of acute stroke patients but, by the tenth day after admission to hospital, only one-third are still hypertensive. The clinical significance of post-stroke hypertension is uncertain and its management is a contentious issue. In this article we review current evidence regarding the risks and benefits of the treatment of post-stroke hypertension. The pathophysiology of post-stroke hypertension is described in relation to autoregulation of cerebral blood flow after cerebral infarction or haemorrhage. In the absence of clinical trial data, recommendations for early treatment of post-stroke hypertension are based on a review of expert opinion that immediate, controlled lowering of blood pressure after acute stroke is required only in defined situations such as hypertensive encephalopathy or aortic dissection. There are no reliable data regarding the comparative effects of different hypotensive agents after acute stroke; short-acting vasodilator drugs are recommended if treatment is essential. The benefits of hypotensive therapy in secondary prevention of recurrent stroke are uncertain but the results of large clinical trials in progress should provide helpful guidelines for clinical practice.