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worsening, higher rates of poor outcomes or death, and larger volumes of infarctions. They noted that the early administration of antihypertensive agents to patients with systolic blood pressures >180 mm Hg was associated with a marked increase in likelihood of early deterioration, poor neurological outcome, or death. Several small inconclusive studies have tested calcium channel–blocking agents, angiotensin-converting enzyme inhibitors, diuretics, β-blockers, and nitrates, with generally inconclusive or conflicting results.256,257 A multicenter, placebo-controlled trial tested the utility of candesartan when started 1 day after stroke.258 The dosage of medication was increased on day 2 if the patient’s systolic blood pressure was >160 mm Hg systolic or >100 mm Hg diastolic. Rescue therapy with intravenous antihypertensive agents was permitted for patients with severely elevated blood pressures. At day 7, other antihypertensive agents could be administered to treat persisting elevated blood pressures. The trial was halted prematurely because of a higher rate of deaths and recurrent vascular events in the placebo-treated group. However, the differences in outcomes were not seen in the first few months after stroke, and the divergence between treatment groups was seen only after 1 year. In a small study, patients were given either captopril or amlodipine for treatment of hypertension beginning 1 day after stroke; moderate reductions in blood pressure were associated with improved short-term outcomes.259 In another small, randomized study, Eames et al260 found no major reduction in blood pressure among patients treated with bendrofluazide, and they concluded that this agent was not effective in treating hypertension after stroke. Large, well-designed trials are needed to clarify the management of arterial hypertension after acute stroke. A trial testing the utility of antihypertensive therapy in the setting of stroke (Controlling Hypertension and Hypotension Immediately Post-Stroke [CHHIPS]) is ongoing.261 Because of the lack of unambiguous data, the appropriate treatment of arterial hypertension in the setting of acute ischemic stroke remains controversial. Although severe hypertension may be considered an indication for treatment, no data define the levels of arterial hypertension that mandate emergency management.247 However, the aforementioned data suggest that the systolic blood pressure level that would prompt treatment would be >180 mm Hg.240 A systolic blood pressure >185 mm Hg or a diastolic blood pressure >110 mm Hg is a contraindication to intravenous administration of rtPA.66,262 Still, it is not clear whether those values should be the threshold for starting emergency treatment outside the setting of administration of rtPA. Although no definitive data from controlled trials are available, in the absence of other organ dysfunction necessitating rapid reduction in blood pressure or in the setting of thrombolytic therapy, there is little scientific evidence and no clinically established benefit for rapid lowering of blood pressure among persons with acute ischemic stroke.247 Some data indicate that rapid and steep reductions in blood pressure might be harmful. Pending more data, the consensus of the panel is that emergency administration of antihypertensive agents should be withheld unless the diastolic blood pressure is >120 mm Hg or unless the systolic blood pressure is >220 mm Hg. The panel recognizes that no data show that these values are especially dangerous and emergency treatment is needed. However, the panel remains concerned by the evidence that aggressive lowering of blood pressure among patients may cause neurological worsening, and the goal is to avoid overtreating patients with stroke until definitive
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