Delayed antihypertensive treatment may not affect outcomes of acute ischemic stroke
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Researchers observed no difference in 3-month functional outcomes or mortality among patients with acute ischemic stroke who underwent early BP-lowering therapy compared with a delayed strategy, a speaker reported.
The results of the CATIS-2 trial were presented at the International Stroke Conference.
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“Increased blood pressure is really common in the acute stage and is strongly associated with poor neurological functions and recurrence of ischemic stroke. We have lots of concern in clinical practice and clinical research about if we do need reduction of the blood pressure at an early stage, what is the optimal timepoint and choice of medications,” Liping Liu, MD, PhD, of the Beijing Tiantan Hospital, Capital Medical University and National Clinical Research Center for Neurological Diseases, said during a presentation. “There is no randomized trial to compare the early or delayed initiation the blood pressure reduction in acute ischemic stroke.”
In the original CATIS trial, researchers evaluated whether moderate BP lowering within the first 48 hours of acute ischemic stroke onset would reduce death or major disability at hospital discharge and 14 days follow-up compared with discontinuation of all antihypertension treatment.
As Healio previously reported, moderate BP lowering within the first 48 hours of acute ischemic stroke onset was not associated with any change in stroke outcomes compared with antihypertensive discontinuation.
CATIS-2 was a multicenter, randomized, open-label, blinded-endpoint trial that tested early antihypertensive treatment compared with delayed antihypertensive treatment for reducing risk for the primary composite outcome of major disability and mortality at 3 months among 4,810 patients with acute ischemic stroke and elevated BP within 24 to 48 hours of stroke symptom onset (mean age, 64 years; 65% men).
Secondary outcomes included first recurrent stroke events within 3-month follow-up.
Participants assigned to early antihypertensive treatment received BP-lowering medication immediately after randomization, with a target systolic BP reduction of 10% to 20% within 24 hours and an average BP less than 140/90 mm Hg within 5 days maintained out to 90 days. Participants assigned to delayed antihypertensive treatment discontinued treatment for the first 7 days after randomization and restarted treatment on day 8, according to the presentation.
At 24 hours after, mean systolic BP was reduced 9.7% in the early-treatment group and 4.9% in the delayed-treatment group (difference, 7.8 mm Hg; 95% CI, 6.7 to 8.9; P < .0001).
At 7 days, mean systolic BP was 139.1 mm Hg in the early-treatment group compared with 150.9 mm Hg in the delayed-treatment group (net difference, 11.9 mm Hg; 95% CI 12.9 to 10.9; P < .0001).
The researchers observed no significant differences in major disability and mortality at 3 months between early and delayed antihypertensive treatment for patients who presented with acute ischemic stroke (OR = 1.17; 95% CI, 0.98-1.4; P = .092).
There was also no significant difference in first recurrent stroke or major vascular events within 3 months between early and delayed antihypertensive treatment groups (recurrent stroke: OR = 1.14; 95% CI, 0.89-1.46 P = .3; major vascular events: OR = 1.08; 95% CI, 0.85-1.38; P = .53).
Liu and colleagues observed no interaction with the primary composite outcome among prespecified subgroups including patients grouped by age, sex, BP at baseline, National Institutes of Health Stroke Scale score, history of hypertension, antihypertensive medication use at baseline and stroke subtype.
“Increased blood pressure is really common and associated with poor neurological function [after acute ischemic stroke], and we do not see any difference [in outcomes with] early blood pressure reduction vs. delayed reductions after day 7, but antihypertension treatment could be delayed at least 7 days of onset unless those with severe acute comorbidities demand emergency blood pressure reductions,” Lui said. “CATIS-2 is first trial to compare the early and delayed blood pressure reduction for acute ischemic stroke and indicate there might be underlying mechanisms of the increased blood pressure in the acute or super acute stage, which should be individually considered. The optimal blood pressure measurement strategy in those patients remains uncertain and should be the focus of future research.”
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Liu L, et al. LB 19. Presented at: International Stroke Conference; Feb. 8-10, 2023; Dallas (hybrid meeting).
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