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The New England Journal of MedicineIntensive Ambulance-Delivered Blood-Pressure Reduction in Hyperacute Stroke

Early Blood-Pressure Management in Prehospital Stroke Care: Insights into Functional Outcomes and Implications for Hemorrhagic vs. Ischemic Stroke

A recent study investigated whether immediate blood-pressure reduction in patients with suspected acute stroke could improve outcomes when initiated in the ambulance. The trial compared intensive blood-pressure management with usual care, aiming to assess the effects on functional status and safety outcomes in a diverse cohort.

Study Design:

  • Participants: 2404 patients with suspected acute stroke and elevated systolic blood pressure (≥150 mm Hg), assessed within 2 hours of symptom onset.
  • Randomization: Patients were randomly assigned to either the intervention group (immediate blood-pressure reduction to 130-140 mm Hg) or the usual-care group.
  • Primary Efficacy Outcome: Functional status at 90 days, assessed by the modified Rankin scale.
  • Primary Safety Outcome: Incidence of serious adverse events.
  • Demographics: Mean age of participants was 70 years; the median time from symptom onset to randomization was 61 minutes.
  • Blood Pressure: Mean initial blood pressure was 178/98 mm Hg.

Key Findings:

  • Overall Functional Outcome: No significant difference between the intervention and usual-care groups (common odds ratio, 1.00; 95% CI, 0.87 to 1.15).
  • Blood Pressure at Hospital Arrival: Mean systolic blood pressure was 159 mm Hg in the intervention group compared to 170 mm Hg in the usual-care group.
  • Stroke Type Confirmation: Imaging confirmed stroke in 2240 patients; 46.5% had hemorrhagic stroke.
  • Impact on Hemorrhagic Stroke: Prehospital blood-pressure reduction decreased the odds of poor functional outcomes (common odds ratio, 0.75; 95% CI, 0.60 to 0.92).
  • Impact on Ischemic Stroke: Prehospital blood-pressure reduction increased the odds of poor functional outcomes (common odds ratio, 1.30; 95% CI, 1.06 to 1.60).
  • Safety: The incidence of serious adverse events was similar in both groups.

HCN Medical Memo
This study suggests that immediate blood-pressure reduction in prehospital stroke management does not universally improve outcomes and may have differing effects depending on the type of stroke. For patients with suspected acute stroke, careful consideration of stroke type is crucial when deciding on early blood-pressure interventions.

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