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Article
August 1993

Should Hypertension Be Treated After Acute Stroke?A Randomized Controlled Trial Using Single Photon Emission Computed Tomography

Author Affiliations

From the Departments of Neurology (Drs Lisk and Grotta), Radiology/Nuclear Medicine (Drs Lamki, Tran, Taylor, and Barron), and Internal Medicine (Dr Molony), University of Texas Health Science Center, Houston.

Arch Neurol. 1993;50(8):855-862. doi:10.1001/archneur.1993.00540080060015
Abstract

• Objective.  —To determine if previously hypertensive patients with acute ischemic stroke should be treated with antihypertensive medication in the immediate poststroke period.

Design.  —Randomized double-blind, placebo-controlled trial.

Setting.  —Acute-care teaching hospital.

Patients.  —Sixteen consecutive hypertensive patients (four men and 12 women; mean age, 66 years [age range, 46 to 83 years]) with middle cerebral artery infarction within 72 hours of onset and blood pressure between 170 and 220 mm Hg (systolic) and 95 and 120 mm Hg (diastolic).

Intervention.  —Placebo (n=6), nicardipine hydrochloride (20 mg [n=5]), captopril (12.5 mg [n=3]), or clonidine hydrochloride (0.1 mg [n=2]) given every 8 hours for 3 days.

Main Outcome Measures.  —Decline in blood pressure, change in cerebral blood flow as measured by single photon emission computed tomography, and clinical change as determined by the National Institutes of Health Stroke Scale.

Results.  —Blood pressure fell significantly in both the drug-treated group as a whole and in those patients receiving placebo (P<.001). There was no difference in blood pressure levels between these two groups throughout the study period. Patients receiving nicardipine had a consistently lower pressure than the other groups. A significant negative relationship was noted between the maximum blood pressure fall and improvement in cerebral blood flow. There were four patients whose blood pressure dropped by more than 16% of the baseline value on any 24 hours in the first 3 days. All either failed to increase or actually decreased their cerebral blood flow to the affected area. Three of these patients were treated with nicardipine. There was no significant difference in clinical course between the placebo- and drug-treated groups as a whole.

Conclusions.  —Hypertensive ischemic stroke patients with a moderate elevation of blood pressure in the first few days may not require antihypertensive therapy. Nicardipine and possibly other calcium channel blockers may cause an excessive fall in blood pressure and impair cerebral blood flow in these patients and should therefore be used with caution.

References
1.
Wallace JD, Levy LL.  Blood pressure after stroke .  JAMA . 1981;246: 2177-2180.Crossref
2.
Yatsu FM, Zivin J.  Hypertension in acute strokes: not to treat .  Arch Neurol . 1985;42:999-1000.Crossref
3.
Spence JD, Del Maestro RF.  Hypertension in acute strokes .  Arch Neurol . 1985;42:1000-1002.Crossref
4.
Lavin P.  Management of hypertension in patients with acute stroke .  Arch Intern Med . 1986;146:66-68.Crossref
5.
Strandgaard S, Paulson OB.  Cerebral blood flow and its pathophysiology .  Am J Hypertens . 1989;2:486-492.
6.
Meyer JS, Shimamzu K, Fukuuchi Y, Ohuchi T, Okamoto S, Ericsson AD, Koto A.  Impaired neurogenic cerebrovascular control and dysautoregulation after stroke .  Stroke . 1973;4:169-186.Crossref
7.
Lamki LM, Barron BJ, Tran HD, Taylor WJ.  Quantification of brain SPECT with Tc-99m HMPAO in 'normal' cases, stroke, epilepsy, and closed head injury .  Radiology . 1992;182:2. Abstract.
8.
Hanson SK, Grotta JC, Maklad NF, Lamki LM, Tran HD, Barron BJ.  CBF tomography and transcranial Doppler in tPA treatment of acute stroke .  J Stroke Cerebrovasc Dis . 1992;2( (suppl 1) ):S149.Crossref
9.
Lyden PR, Lau GT.  A critical appraisal of stroke evaluation and rating scales .  Stroke . 1991;22:1345-1352.Crossref
10.
Goldstein LB, Bartels C, Davis JN.  Interrater reliability of the NIH Stroke Scale .  Arch Neurol . 1989;46:660-662.Crossref
11.
Britton M, DeFaire U, Helmers C.  Hazards of therapy for excessive hypertension in acute stroke .  Acta Med Scand . 1980;207:253-257.Crossref
12.
Meyer JS, Sawada T, Kitamura A, Toyoda M.  Cerebral blood flow after control of hypertension in stroke .  Neurology . 1968;18:772-781.Crossref
13.
Britton M, Carlsson A, DeFaire U.  Blood pressure course in patients with acute stroke and matched controls .  Stroke . 1986;17:861-864.Crossref
14.
DeFaire U, Britton M, Helmers C, Webster PO.  Blood pressure during the acute phases of cerebrovascular disease .  Acta Med Scand Suppl . 1978; 621:27. Abstract.
15.
Rosenbaum D, Zabramski J, Frey J, Yatsu JF, Marler J, Spetzler R.  Early treatment of ischemic stroke with a calcium antagonist .  Stroke . 1991;22: 437-441.Crossref
16.
Grotta J.  Clinical aspects of the use of calcium antagonists in cerebrovascular disease .  Clin Neuropharmacol . 1991;14:373-390.Crossref
17.
Carlberg B, Asplund K, Hagg E.  Factors influencing admission blood pressure levels in patients with acute stroke .  Stroke . 1991;22:527-530.Crossref
18.
Waltz AG.  Effect of blood pressure on blood flow in ischemic and in nonischemic cerebral cortex .  Neurology . 1968;18:613-621.Crossref
19.
Britton KE, Granowska M, Nimmon CC, Horne T.  Cerebral blood flow in hypertensive patients with cerebrovascular disease: technique for measurement and effect of captopril .  Nucl Med Commun . 1985;6:251-261.Crossref
20.
Flamm ES, Adams HP, Beck DW, Pinto RS.  Dose-escalation study of intravenous nicardipine in patients with aneurysmal subarachnoid hemorrhage .  J Neurosurg . 1988;68:393-400.Crossref
21.
Fagan SC, Payme W, Houtekier SC.  Risk of cerebral hypoperfusion with antihypertensive therapy .  DICP . 1989;23:957-962.
22.
Conen D, Bartel O, Dubach UC.  Cerebral blood flow and calcium antagonists in hypertension .  J Hypertens . 1987;5( (suppl 4) ):S75-S80.Crossref
23.
Gelmers HJ.  The effects of nimodipine on the clinical course of patients with acute ischemic stroke .  Acta Neurol Scand . 1984;69:232-239.Crossref
24.
Mohammed AA, McCulloch J, Mendelow AD, Teasdale GM, Harper AM.  Effect of the calcium antagonist nimodipine on local cerebral blood flow: relationship to arterial blood pressure .  J Cereb Blood Flow Metab . 1984;4: 206-211.Crossref
25.
Bartel O, Conen D, Radu EW, Muller J, Lang C, Dubach UC.  Nifedipine in hypertensive emergencies .  BMJ . 1983;286:19-21.Crossref
26.
Fieschi C, Angoli A, Battistini N, Bozzao L, Prencipe M.  Derangement of regional blood flow and of its regulatory mechanisms in acute cerebrovascular lesions .  Neurology . 1968;18:1166-1179.Crossref
27.
Vorstrup S, Andersen A, Blegvad N, Paulson OB.  Calcium antagonist (PY 108-068) treatment may further decrease flow in ischemic areas in acute stroke .  J Cereb Blood Flow Metab . 1986;6:222-229.Crossref
28.
Rajagopalan B, Raine AEG, Cooper R, Ledingham JGG.  Changes in cerebral blood flow in patients with severe congestive cardiac failure before and after captopril treatment .  Am J Med . 1984;76:86-90.Crossref
29.
Waldemar G, Vorstrup S, Andersen AR, Pedersen H, Paulson O.  Angiotensin-converting enzyme inhibition and regional cerebral blood flow in acute stroke .  J Cardiovasc Pharmacol . 1989;14:722-729.Crossref
30.
Bartel O, Conen LD.  Treatment of hypertensive emergencies with the calcium channel blocker nifedipine .  Am J Med . 1985;79( (suppl 4A) ):31-35.Crossref
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