Using the blood pressure-lowering drug candesartan in patients who have high blood pressure in the acute phase of stroke does not give any benefit, and may actually be harmful. The findings of the SCAST study are being published in an Article Online First by The Lancet that coincides with the presentation of the paper at the International Stroke Conference in Los Angeles. The study is by Dr Else Charlotte Sandset and Dr Eivind Berge, Oslo University Hospital Ullevål, Norway, and colleagues.
The best way to manage high blood pressure in acute stroke is not known, and current practice is to accept high blood pressure in this situation. Candesartan belongs to the family of drugs called angiotensin-receptor blockers, used to lower blood pressure, and the authors studied the effects of this drug in acute stroke patients.
Patients aged 18 years and over with acute stroke and systolic blood pressure above 140 mm Hg were allocated to either candesartan (1017 patients) or placebo (1012) for 7 days. During the 7-day treatment period, blood pressures were significantly lower in patients given candesartan (147/82 mm Hg vs 152/84 in placebo group). But during 6 months' follow-up, risk of vascular death, stroke, or heart attack did not differ significantly between the two groups. The analysis also revealed that patients given candesartan were more likely to have a poor outcome than patients given placebo, although this finding was not statistically significant. The results were the same in all pre-specified subgroups, and for all secondary endpoints. Nine patients in the candesartan group experienced symptoms due to low blood pressure versus 5 in the placebo group, and kidney failure was also more frequent in the candesartan group (18 patients) than the placebo group (13 patients). The authors also did a meta-analysis including these findings, which further confirmed the lack of beneficial effect.
The authors say: "Our results showed no beneficial effect of blood-pressure lowering treatment with the angiotensin-receptor blocker candesartan in patients with acute stroke and raised blood pressure...Other trials are ongoing, but until these trials have been completed we see no place for routine blood pressure lowering treatment in the acute phase of stroke."
In a linked Comment, Professor Graeme J Hankey, Stroke Unit, Royal Perth Hospital and University of Western Australia, Perth, WA, Australia, says: "The results of SCAST, when added to the results of the ten previous trials of lowering of blood pressure in acute stroke, increase the reliability of the evidence and indicate that, in acute stroke, pharmacologically lowering blood pressure does not have an overall beneficial effect on functional outcome…Clinicians should therefore not be prescribing blood pressure-lowering drugs within the first week of acute stroke in routine practice."
He adds however that it is uncertain whether other blood pressure-lowering strategies in acute stroke could have favourable effects on outcome, and like the Article authors awaits the results of some ongoing studies to gain more evidence.
Dr Eivind Berge, Oslo University Hospital Ullevål, Norway. T) +47 91612226 or +47 99216550 (Dept of Public Relations) E) eivind.berge@medisin.uio.no
Professor Graeme J Hankey, Stroke Unit, Royal Perth Hospital and University of Western Australia, Perth, WA, Australia. T) + 61 404 894 071 E) gjhankey@cyllene.uwa.edu.au
For full Article and Comment see: http://press.thelancet.com/scast.pdf
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Journal
The Lancet