CardioExchange Archive

CardioExchange, an NEJM practice community for medical professionals dedicated to improving cardiac patient care, was active from 2009 to 2015. CardioExchange fostered discussion between clinicians from across the globe.

February 11th, 2011

SCAST Trial Provides No Support for Blood Pressure Lowering in Acute Stroke

Lowering blood pressure with an angiotensin-receptor blocker in patients with acute stroke and hypertension produces no benefits, according to a new study presented at the International Stroke Conference and published simultaneously online in the Lancet. In the Scandinavian Candesartan Acute Stroke Trial (SCAST), investigators randomized 2029 acute stroke patients in 9 north European countries who had a systolic blood pressure of 140 mm Hg or higher to candesartan or placebo.

At 6 months, the rate of vascular death, MI, or stroke was not significantly different between the two groups (120 events in the candesartan group versus 111 events in the placebo group, p=0.52). In addition, functional outcome at 6 months as assessed by the modified Rankin Scale was not significantly different between the groups, though a trend suggested a worse outcome in the candesartan group (p=0.048).

The investigators concluded that unless other ongoing trials suggest otherwise, “we see no place for routine blood-pressure lowering treatment in the acute phase of stroke.”

In an accompanying comment, Graeme Hankey writes that the results of the trial, taken with the results of previous trials, suggest that “pharmacologically lowering blood pressure does not have an overall beneficial effect on functional outcome” and that therefore “clinicians should… not be prescribing blood-pressure-lowering drugs within the first week of acute stroke in routine practice.”

Categories: General, Vascular
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2 Responses to “SCAST Trial Provides No Support for Blood Pressure Lowering in Acute Stroke”

  1. Stephen Sokol, MD, DTMPH says:
    February 27, 2011 at 1:19 pm

    I would like to know the range of BPs observed as I was taught that pressures over 200 systolic should be lowered to the 160-170 range.

    Competing interests pertaining specifically to this post, comment, or both:
    none as I am only salaried by my university

  2. Susan Cheng, MD says:
    March 1, 2011 at 1:07 am

    Great point, as I was taught the same thing. Turns out that acute stroke is considered a special case, and experts fear that lowering elevated BP in this setting — even if it’s very high — could do more harm than good (likely due to hypoperfusion in vulnerable territories). Fortunately, most patients with acute stroke and extreme hypertension drop their BP within hours of presentation, even without treatment. It’s those with BPs that stay really high that even the experts don’t know what to do about. So current guidelines actually recommend (in the absence of data) not to treat SBP <=220 or DBP <=120. Even though the study authors don't make it at all clear what their range is, judging by the mean and SD values in Table 1, looks like 85% of patients had SBP <=190 and 98% had SBP <=209. Based on the main study results, it seems that acute stroke is indeed a special case (given all the stuff we learned about treating other types of hypertensive emergencies)…