The angiotensin-receptor blocker candesartan didn’t improve outcomes.

In patients with acute ischemic stroke, guidelines recommend withholding antihypertensive treatment until systolic blood pressure exceeds 220 mm Hg or diastolic BP exceeds 120 mm Hg . A slightly lower threshold (180–200 mm Hg) is recommended in patients with hemorrhagic stroke . However, hard evidence is lacking to support any particular threshold.

In this randomized European trial, 2000 patients with acute stroke (86% ischemic; 14% hemorrhagic) and systolic BP >140 mm Hg received 7-day courses of either placebo or the angiotensin-receptor blocker candesartan (Atacand; dose titrated to 16 mg, if necessary). Mean BP at enrollment was 171/90 mm Hg; during treatment, mean systolic BP averaged 3 to 5 mm Hg lower with candesartan than with placebo.

During the 7-day treatment phase, neurological status (according to a standardized stroke scale) was similar in the candesartan and placebo groups, but 6-month functional status was marginally worse in the candesartan group (P=0.05). At 6 months, a primary composite vascular endpoint (stroke, myocardial infarction, vascular death) had occurred with similar frequency in the two groups. Candesartan therapy did not benefit patients with the highest baseline systolic BPs (i.e., >180 or >200 mm Hg) or patients with hemorrhagic strokes.

Comment: Candesartan does not improve outcomes in patients with acute stroke. Note, however, that this trial hardly tested the effect of BP lowering, given the difference of only 3 to 5 mm Hg systolic BP between groups. The researchers postulated that candesartan might confer benefit both through lowering BP and through non–BP-related neuroprotective mechanisms, but that didn’t happen. Clinicians should follow the above-referenced guidelines, unless future studies generate persuasive evidence to lower treatment thresholds.

Source:Journal Watch General Medicine