Letter by Simone Vidale Regarding Article,“Relation Between Change in Blood Pressure in Acute Stroke and Risk of Early Adverse Events and Poor Outcome”

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HomeStrokeVol. 43, No. 12Letter by Simone Vidale Regarding Article,“Relation Between Change in Blood Pressure in Acute Stroke and Risk of Early Adverse Events and Poor Outcome” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Simone Vidale Regarding Article,“Relation Between Change in Blood Pressure in Acute Stroke and Risk of Early Adverse Events and Poor Outcome” Simone Vidale, MD Simone VidaleSimone Vidale Department of Neurology, Sant’Anna Hospital, Como, Italy Search for more papers by this author Originally published15 Nov 2012https://doi.org/10.1161/STROKEAHA.112.674572Stroke. 2012;43:e176Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2012: Previous Version 1 To the Editor:I read with great interest “Relation Between Change in Blood Pressure in Acute Stroke and Risk of Early Adverse Events and Poor Outcome” by Sandset et al.1 The article focused on the effects of change in systolic blood pressure (BP) in the acute phase of stroke on clinical and radiological outcomes. In this subanalysis of Scandinavian Candesartan Acute Stroke Trial (SCAST), the authors identified the early adverse events (recurrent stroke, stroke progression, and symptomatic hypotension) as primary effects and mid-term and long-term clinical and functional outcomes as secondary effects. In the results, although a small decrease in SBP was not related to an increase of early adverse events, they observed a higher risk of poor neurological outcome in the patient group with increase or no change in SBP. They concluded that a routine blood pressure (BP)-lowering treatment should be avoided in the acute phase of stroke. These are also the current evidences from literature with conflicting results.2,3 The European Stroke Organization, the Stroke Council of the American Heart Association/American Stroke Association, and the Italian current guidelines recommend that antihypertensive treatment should be initiated with caution at BP >220/120 mmHg on repeated measurements in ischemic stroke patients. This concept of multiple measurements is based on new and emerging evidences that variability and change in BP could contribute more than a single assessment.4 The hypertensive response and increase of BP in acute phase of stroke are multifactorial and not completely understood. However, the turning point could be the reperfusion process of the brain damaged area. Elevated intracranial pressure, decreased parasympathetic activity, stress from hospitalization and injury to areas of BP, and autonomic control in the brain could contribute to elevation of BP. It is also interesting in the article by Sandset et al that a large decrease in SBP is not related to poor neurological outcome. In this way, it could be hypothesized that recurrent stroke, stroke progression, or symptomatic hypotension are not always related to mid-term and long-term poor functional outcomes. Considering this effect, as reported in a previous work by Ahmed et al,5 it would be interesting to explore in SCAST the same association between high SBP after thrombolysis and poor outcome. Second, a subanalysis of type and localization of ischemic strokes could contribute to better-understand the role of SBP change in early adverse effects. Although BP management in acute stroke represents a gray therapeutic area, it is of growing knowledge with potential to impact patient outcome. For example, from last evidences, ischemic stroke patients with hypotension or significant decrease in BP could benefit from inducted hypertension. Obviously, future studies are warranted to answer to this and other open-questions.Simone Vidale, MDDepartment of NeurologySant'Anna HospitalComo, ItalyDisclosuresNone.FootnotesStroke welcomes Letters to the Editor and will publish them, if suitable, as space permits. Letters must reference a Stroke published-ahead-of-print article or an article printed within the past 3 weeks. The maximum length is 750 words including no more than 5 references and 3 authors. Please submit letters typed double-spaced. Letters may be shortened or edited. Include a completed copyright transfer agreement form (available online at http://stroke.ahajournals.org and http://submit-stroke.ahajournals.org).