Vasoactive drugs for acute stroke.
BACKGROUND
It is unclear whether blood pressure (BP) should be altered actively during the acute phase of stroke.


OBJECTIVE
To assess the effect of lowering or elevating BP in people with acute stroke, and the effect of different vasoactive drugs on BP in acute stroke.


METHODS
We searched the Cochrane Stroke Group Trials Register (last searched June 2009), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2009), MEDLINE (1966 to October 2009), EMBASE (1980 to October 2009), and Science Citation Index (1981 to October 2009).


METHODS
Randomised trials of interventions that would be expected, on pharmacological grounds, to alter BP in patients within one week of the onset of acute stroke.


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


RESULTS
We identified 131 trials involving in excess of 18,000 patients; a further 13 trials are ongoing. We obtained data for 43 trials (7649 patients). Among BP-lowering trials, beta receptor antagonists lowered BP (early systolic BP (SBP) mean difference (MD) -6.1 mmHg, 95% CI -11.4 to -0.9; late SBP MD -4.9 mmHg, 95% CI -10.2 to 0.4; late diastolic BP (DBP) MD -4.5 mmHg, 95% CI -7.8 to -1.2). Oral calcium channel blockers (CCB) lowered BP (late SBP MD -3.2 mmHg, 95% CI -5.4 to -1.1; early DBP MD -2.5, 95% CI -5.6 to 0.7; late DBP MD -2.1, 95% CI -3.5 to -0.7). Nitric oxide donors lowered BP (early SBP MD -10.3 mmHg, 95% CI -17.6 to -3.0). Prostacyclin lowered BP (late SBP MD, -7.7 mmHg, 95% CI -15.6 to 0.2; late DBP MD -3.9 mmHg, 95% CI -8.1 to 0.4). Among BP-increasing trials, diaspirin cross-linked haemoglobin (DCLHb) increased BP (early SBP MD 15.3 mmHg, 95% CI 4.0 to 26.6; late SBP MD 15.9 mmHg, 95% CI 1.8 to 30.0). None of the drug classes significantly altered outcome apart from DCLHb which increased combined death or dependency (odds ratio (OR) 5.41, 95% CI 1.87 to 15.64).


CONCLUSIONS
There is not enough evidence to evaluate reliably the effect of altering BP on outcome after acute stroke. However, treatment with DCLHb was associated with poor clinical outcomes. Beta receptor antagonists, CCBs, nitric oxide, and prostacyclin each lowered BP during the acute phase of stroke. In contrast, DCLHb increased BP.
Geeganage
Chamila
C
Division of Stroke Medicine, University of Nottingham, Nottingham City Hospital Campus, Hucknall Road, Nottingham, UK, NG5 1PB.
Bath
Philip Mw
PM
D000284:Administration, Oral; D000328:Adult; D000959:Antihypertensive Agents / Q000627:therapeutic use*; D001241:Aspirin / Q000009:adverse effects / Q000031:analogs & derivatives; D001794:Blood Pressure / Q000187:drug effects* / Q000502:physiology; D006454:Hemoglobins / Q000009:adverse effects; D006801:Humans; D006973:Hypertension / Q000188:drug therapy*; D007022:Hypotension / Q000188:drug therapy*; D007275:Injections, Intravenous; D016032:Randomized Controlled Trials as Topic; D020521:Stroke / Q000188:drug therapy* / Q000503:physiopathology; D014662:Vasoconstrictor Agents / Q000627:therapeutic use; D014665:Vasodilator Agents / Q000627:therapeutic use
D000959:Antihypertensive Agents; D006454:Hemoglobins; D014662:Vasoconstrictor Agents; D014665:Vasodilator Agents; C083478:diaspirin-cross-linked hemoglobin; D001241:Aspirin