Impact of early blood pressure reduction on the prognosis of acute ischemic stroke: a meta-analysis_West China Medical Journal

Authors：

MAO Fengkai ¹ , LIN Yapeng ¹ , HE Song ¹ , TAN Quandan ¹ , TAN Song ² ,  YANG Jie ²

1. Department of Neurology, the First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan 610500, P. R. China;
2. Department of Neurology & Institute of Neurology, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan 610500, P. R. China;

Corresponding author：

YANG Jie, Email: yangjie1126@163.com

Keywords：

Acute ischemic stroke; early blood pressure reduction; prognosis; meta-analysis

DOI：

10.7507/1002-0179.202405024

Video：

Export PDF Favorites Scan Get Citation

Abstract Full text Figures/Tables Video References Cited by

Objective To explore the impact of early blood pressure reduction on the prognosis of acute ischemic stroke. Methods We searched PubMed, Embase, Cochrane Library, Wanfang, China National Knowledge Infrastructure, and Chongqing VIP, with the search period from databases establishment to December 31, 2024. Randomized controlled studies on early blood pressure reduction within 7 days after the onset of acute ischemic stroke were included, and meta-analysis was conducted using RevMan 5.4 software. Results Finally, 15 randomized controlled studies were included. The meta-analysis results showed that there was no statistically significant difference in the primary outcome (90 days disability or death) and the secondary outcomes (90 days all-cause death) between the early blood pressure reduction group and the control group (P>0.05). Compared with the control group, the early blood pressure reduction group had a higher National Institute of Health Stroke Scale score at 2 weeks [standardized mean difference=0.25, 95% confidence interval (0.07, 0.44), P=0.008]. Conclusion Early blood pressure reduction cannot reduce the risk of 90 days disability or death and 90 days all-cause death in patients with acute ischemic stroke, and may be detrimental to 2 weeks neurological function recovery.

Citation： MAO Fengkai, LIN Yapeng, HE Song, TAN Quandan, TAN Song, YANG Jie. Impact of early blood pressure reduction on the prognosis of acute ischemic stroke: a meta-analysis. West China Medical Journal, 2025, 40(5): 698-703. doi: 10.7507/1002-0179.202405024 Copy

1.	GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet, 2020, 396(10258): 1204-1222.
2.	Katan M, Luft A. Global burden of stroke. Semin Neurol, 2018, 38(2): 208-211.
3.	Johnson W, Onuma O, Owolabi M, et al. Stroke: a global response is needed. Bull World Health Organ, 2016, 94(9): 634-634A.
4.	Wu S, Wu B, Liu M, et al. Stroke in China: advances and challenges in epidemiology, prevention, and management. Lancet Neurol, 2019, 18(4): 394-405.
5.	Feigin VL, Lawes CM, Bennett DA, et al. Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review. Lancet Neurol, 2009, 8(4): 355-369.
6.	Tikhonoff V, Zhang H, Richart T, et al. Blood pressure as a prognostic factor after acute stroke. Lancet Neurol, 2009, 8(10): 938-948.
7.	Qureshi AI, Ezzeddine MA, Nasar A, et al. Prevalence of elevated blood pressure in 563, 704 adult patients with stroke presenting to the ED in the United States. Am J Emerg Med, 2007, 25(1): 32-38.
8.	中华人民共和国国家卫生健康委员会. 脑血管病防治指南(2024 年版). 磁共振成像, 2025, 16(1): 1-8.
9.	Geeganage CM, Bath PM. Relationship between therapeutic changes in blood pressure and outcomes in acute stroke: a metaregression. Hypertension, 2009, 54(4): 775-781.
10.	Qureshi AI. Acute hypertensive response in patients with stroke: pathophysiology and management. Circulation, 2008, 118(2): 176-187.
11.	Alqadri SL, Sreenivasan V, Qureshi AI. Acute hypertensive response management in patients with acute stroke. Curr Cardiol Rep, 2013, 15(12): 426.
12.	Carlberg B, Asplund K, Hägg E. Factors influencing admission blood pressure levels in patients with acute stroke. Stroke, 1991, 22(4): 527-530.
13.	Yatsu FM, Zivin J. Hypertension in acute ischemic strokes. Not to treat. Arch Neurol, 1985, 42(10): 999-1000.
14.	Spence JD, Del Maestro RF. Hypertension in acute ischemic strokes. Treat. Arch Neurol, 1985, 42(10): 1000-1002.
15.	Hachinski V. Hypertension in acute ischemic strokes. Arch Neurol, 1985, 42(10): 1002.
16.	Potter JF, Robinson TG, Ford GA, et al. Controlling hypertension and hypotension immediately post-stroke (CHHIPS): a randomised, placebo-controlled, double-blind pilot trial. Lancet Neurol, 2009, 8(1): 48-56.
17.	Schrader J, Lüders S, Kulschewski A, et al. The ACCESS Study: evaluation of acute candesartan cilexetil therapy in stroke survivors. Stroke, 2003, 34(7): 1699-1703.
18.	He J, Zhang Y, Xu T, et al. Effects of immediate blood pressure reduction on death and major disability in patients with acute ischemic stroke: the CATIS randomized clinical trial. JAMA, 2014, 311(5): 479-489.
19.	Robinson TG, Potter JF, Ford GA, et al. Effects of antihypertensive treatment after acute stroke in the Continue or Stop Post-Stroke Antihypertensives Collaborative Study (COSSACS): a prospective, randomised, open, blinded-endpoint trial. Lancet Neurol, 2010, 9(8): 767-775.
20.	Rashid P, Weaver C, Leonardi-Bee J, et al. The effects of transdermal glyceryl trinitrate, a nitric oxide donor, on blood pressure, cerebral and cardiac hemodynamics, and plasma nitric oxide levels in acute stroke. J Stroke Cerebrovasc Dis, 2003, 12(3): 143-151.
21.	Ahmed N, Näsman P, Wahlgren NG. Effect of intravenous nimodipine on blood pressure and outcome after acute stroke. Stroke, 2000, 31(6): 1250-1255.
22.	Wang H, Tang Y, Rong X, et al. Effects of early blood pressure lowering on early and long-term outcomes after acute stroke: an updated meta-analysis. PLoS One, 2014, 9(5): e97917.
23.	Sandset EC, Murray GD, Bath PM, et al. Relation between change in blood pressure in acute stroke and risk of early adverse events and poor outcome. Stroke, 2012, 43(8): 2108-2114.
24.	Sandset EC, Bath PM, Boysen G, et al. The angiotensin-receptor blocker candesartan for treatment of acute stroke (SCAST): a randomised, placebo-controlled, double-blind trial. Lancet, 2011, 377(9767): 741-750.
25.	Bath PM, Appleton JP, Krishnan K, et al. Blood pressure in acute stroke: to treat or not to treat: that is still the question. Stroke, 2018, 49(7): 1784-1790.
26.	Higgins JPT, Thomas J, Chandler J. Cochrane handbook for systematic reviews of interventions version 6.4. London: Cochrane, 2023.
27.	Liu L, Xie X, Pan Y, et al. Early versus delayed antihypertensive treatment in patients with acute ischaemic stroke: multicentre, open label, randomised, controlled trial. BMJ, 2023, 383: e076448.
28.	李东岳, 李群伟, 孔艳, 等. 基线血压水平与急性缺血性脑卒中早期降压治疗 3 个月结局的关系. 中风与神经疾病杂志, 2021, 38(1): 42-45.
29.	RIGHT-2 Investigators. Prehospital transdermal glyceryl trinitrate in patients with ultra-acute presumed stroke (RIGHT-2): an ambulance-based, randomised, sham-controlled, blinded, phase 3 trial. Lancet, 2019, 393(10175): 1009-1020.
30.	Li Y, Zhong Z, Luo S, et al. Efficacy of antihypertensive therapy in the acute stage of cerebral infarction - a prospective, randomized control trial. Acta Cardiol Sin, 2018, 34(6): 502-510.
31.	包英姝. 脑血栓形成急性期降血压治疗对患者神经功能和生活质量的影响. 中西医结合心血管病电子杂志, 2016, 4(19): 85, 88.
32.	Oh MS, Yu KH, Hong KS, et al. Modest blood pressure reduction with valsartan in acute ischemic stroke: a prospective, randomized, open-label, blinded-end-point trial. Int J Stroke, 2015, 10(5): 745-751.
33.	ENOS Trial Investigators. Efficacy of nitric oxide, with or without continuing antihypertensive treatment, for management of high blood pressure in acute stroke (ENOS): a partial-factorial randomised controlled trial. Lancet, 2015, 385(9968): 617-628.
34.	Ankolekar S, Fuller M, Cross I, et al. Feasibility of an ambulance-based stroke trial, and safety of glyceryl trinitrate in ultra-acute stroke: the rapid intervention with glyceryl trinitrate in Hypertensive Stroke Trial (RIGHT, ISRCTN66434824). Stroke, 2013, 44(11): 3120-3128.
35.	Bath PM, Martin RH, Palesch Y, et al. Effect of telmisartan on functional outcome, recurrence, and blood pressure in patients with acute mild ischemic stroke: a PRoFESS subgroup analysis. Stroke, 2009, 40(11): 3541-3546.
36.	Eveson DJ, Robinson TG, Potter JF. Lisinopril for the treatment of hypertension within the first 24 hours of acute ischemic stroke and follow-up. Am J Hypertens, 2007, 20(3): 270-277.
37.	农文军, 吴玉花, 范维维. 脑梗死急性期血压干预对预后的影响. 广西医科大学学报, 2005, 22(4): 557-558.
38.	Horn J, de Haan RJ, Vermeulen M, et al. Very Early Nimodipine Use in Stroke (VENUS): a randomized, double-blind, placebo-controlled trial. Stroke, 2001, 32(2): 461-465.
39.	Squire IB, Lees KR, Pryse-Phillips W, et al. The effects of lifarizine in acute cerebral infarction: a pilot safety study. Cerebrovasc Dis, 1996, 6: 156-160.
40.	Kaste M, Fogelholm R, Erilä T, et al. A randomized, double-blind, placebo-controlled trial of nimodipine in acute ischemic hemispheric stroke. Stroke, 1994, 25(7): 1348-1353.
41.	Li G, Lin Y, Yang J, et al. Intensive ambulance-delivered blood-pressure reduction in hyperacute stroke. N Engl J Med, 2024, 390(20): 1862-1872.

1. GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet, 2020, 396(10258): 1204-1222.
2. Katan M, Luft A. Global burden of stroke. Semin Neurol, 2018, 38(2): 208-211.
3. Johnson W, Onuma O, Owolabi M, et al. Stroke: a global response is needed. Bull World Health Organ, 2016, 94(9): 634-634A.
4. Wu S, Wu B, Liu M, et al. Stroke in China: advances and challenges in epidemiology, prevention, and management. Lancet Neurol, 2019, 18(4): 394-405.
5. Feigin VL, Lawes CM, Bennett DA, et al. Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review. Lancet Neurol, 2009, 8(4): 355-369.
6. Tikhonoff V, Zhang H, Richart T, et al. Blood pressure as a prognostic factor after acute stroke. Lancet Neurol, 2009, 8(10): 938-948.
7. Qureshi AI, Ezzeddine MA, Nasar A, et al. Prevalence of elevated blood pressure in 563, 704 adult patients with stroke presenting to the ED in the United States. Am J Emerg Med, 2007, 25(1): 32-38.
8. 中华人民共和国国家卫生健康委员会. 脑血管病防治指南(2024 年版). 磁共振成像, 2025, 16(1): 1-8.
9. Geeganage CM, Bath PM. Relationship between therapeutic changes in blood pressure and outcomes in acute stroke: a metaregression. Hypertension, 2009, 54(4): 775-781.
10. Qureshi AI. Acute hypertensive response in patients with stroke: pathophysiology and management. Circulation, 2008, 118(2): 176-187.
11. Alqadri SL, Sreenivasan V, Qureshi AI. Acute hypertensive response management in patients with acute stroke. Curr Cardiol Rep, 2013, 15(12): 426.
12. Carlberg B, Asplund K, Hägg E. Factors influencing admission blood pressure levels in patients with acute stroke. Stroke, 1991, 22(4): 527-530.
13. Yatsu FM, Zivin J. Hypertension in acute ischemic strokes. Not to treat. Arch Neurol, 1985, 42(10): 999-1000.
14. Spence JD, Del Maestro RF. Hypertension in acute ischemic strokes. Treat. Arch Neurol, 1985, 42(10): 1000-1002.
15. Hachinski V. Hypertension in acute ischemic strokes. Arch Neurol, 1985, 42(10): 1002.
16. Potter JF, Robinson TG, Ford GA, et al. Controlling hypertension and hypotension immediately post-stroke (CHHIPS): a randomised, placebo-controlled, double-blind pilot trial. Lancet Neurol, 2009, 8(1): 48-56.
17. Schrader J, Lüders S, Kulschewski A, et al. The ACCESS Study: evaluation of acute candesartan cilexetil therapy in stroke survivors. Stroke, 2003, 34(7): 1699-1703.
18. He J, Zhang Y, Xu T, et al. Effects of immediate blood pressure reduction on death and major disability in patients with acute ischemic stroke: the CATIS randomized clinical trial. JAMA, 2014, 311(5): 479-489.
19. Robinson TG, Potter JF, Ford GA, et al. Effects of antihypertensive treatment after acute stroke in the Continue or Stop Post-Stroke Antihypertensives Collaborative Study (COSSACS): a prospective, randomised, open, blinded-endpoint trial. Lancet Neurol, 2010, 9(8): 767-775.
20. Rashid P, Weaver C, Leonardi-Bee J, et al. The effects of transdermal glyceryl trinitrate, a nitric oxide donor, on blood pressure, cerebral and cardiac hemodynamics, and plasma nitric oxide levels in acute stroke. J Stroke Cerebrovasc Dis, 2003, 12(3): 143-151.
21. Ahmed N, Näsman P, Wahlgren NG. Effect of intravenous nimodipine on blood pressure and outcome after acute stroke. Stroke, 2000, 31(6): 1250-1255.
22. Wang H, Tang Y, Rong X, et al. Effects of early blood pressure lowering on early and long-term outcomes after acute stroke: an updated meta-analysis. PLoS One, 2014, 9(5): e97917.
23. Sandset EC, Murray GD, Bath PM, et al. Relation between change in blood pressure in acute stroke and risk of early adverse events and poor outcome. Stroke, 2012, 43(8): 2108-2114.
24. Sandset EC, Bath PM, Boysen G, et al. The angiotensin-receptor blocker candesartan for treatment of acute stroke (SCAST): a randomised, placebo-controlled, double-blind trial. Lancet, 2011, 377(9767): 741-750.
25. Bath PM, Appleton JP, Krishnan K, et al. Blood pressure in acute stroke: to treat or not to treat: that is still the question. Stroke, 2018, 49(7): 1784-1790.
26. Higgins JPT, Thomas J, Chandler J. Cochrane handbook for systematic reviews of interventions version 6.4. London: Cochrane, 2023.
27. Liu L, Xie X, Pan Y, et al. Early versus delayed antihypertensive treatment in patients with acute ischaemic stroke: multicentre, open label, randomised, controlled trial. BMJ, 2023, 383: e076448.
28. 李东岳, 李群伟, 孔艳, 等. 基线血压水平与急性缺血性脑卒中早期降压治疗 3 个月结局的关系. 中风与神经疾病杂志, 2021, 38(1): 42-45.
29. RIGHT-2 Investigators. Prehospital transdermal glyceryl trinitrate in patients with ultra-acute presumed stroke (RIGHT-2): an ambulance-based, randomised, sham-controlled, blinded, phase 3 trial. Lancet, 2019, 393(10175): 1009-1020.
30. Li Y, Zhong Z, Luo S, et al. Efficacy of antihypertensive therapy in the acute stage of cerebral infarction - a prospective, randomized control trial. Acta Cardiol Sin, 2018, 34(6): 502-510.
31. 包英姝. 脑血栓形成急性期降血压治疗对患者神经功能和生活质量的影响. 中西医结合心血管病电子杂志, 2016, 4(19): 85, 88.
32. Oh MS, Yu KH, Hong KS, et al. Modest blood pressure reduction with valsartan in acute ischemic stroke: a prospective, randomized, open-label, blinded-end-point trial. Int J Stroke, 2015, 10(5): 745-751.
33. ENOS Trial Investigators. Efficacy of nitric oxide, with or without continuing antihypertensive treatment, for management of high blood pressure in acute stroke (ENOS): a partial-factorial randomised controlled trial. Lancet, 2015, 385(9968): 617-628.
34. Ankolekar S, Fuller M, Cross I, et al. Feasibility of an ambulance-based stroke trial, and safety of glyceryl trinitrate in ultra-acute stroke: the rapid intervention with glyceryl trinitrate in Hypertensive Stroke Trial (RIGHT, ISRCTN66434824). Stroke, 2013, 44(11): 3120-3128.
35. Bath PM, Martin RH, Palesch Y, et al. Effect of telmisartan on functional outcome, recurrence, and blood pressure in patients with acute mild ischemic stroke: a PRoFESS subgroup analysis. Stroke, 2009, 40(11): 3541-3546.
36. Eveson DJ, Robinson TG, Potter JF. Lisinopril for the treatment of hypertension within the first 24 hours of acute ischemic stroke and follow-up. Am J Hypertens, 2007, 20(3): 270-277.
37. 农文军, 吴玉花, 范维维. 脑梗死急性期血压干预对预后的影响. 广西医科大学学报, 2005, 22(4): 557-558.
38. Horn J, de Haan RJ, Vermeulen M, et al. Very Early Nimodipine Use in Stroke (VENUS): a randomized, double-blind, placebo-controlled trial. Stroke, 2001, 32(2): 461-465.
39. Squire IB, Lees KR, Pryse-Phillips W, et al. The effects of lifarizine in acute cerebral infarction: a pilot safety study. Cerebrovasc Dis, 1996, 6: 156-160.
40. Kaste M, Fogelholm R, Erilä T, et al. A randomized, double-blind, placebo-controlled trial of nimodipine in acute ischemic hemispheric stroke. Stroke, 1994, 25(7): 1348-1353.
41. Li G, Lin Y, Yang J, et al. Intensive ambulance-delivered blood-pressure reduction in hyperacute stroke. N Engl J Med, 2024, 390(20): 1862-1872.

West China Medical Journal

Impact of early blood pressure reduction on the prognosis of acute ischemic stroke: a meta-analysis

Abstract Full text Figures/Tables Video References Cited by

Previous Article

Next Article

Format

Content