Elevated pretreatment blood pressure and IV thrombolysis in stroke

Objectives: We investigated whether an active blood pressure–lowering strategy is associated with more patients receiving thrombolytics compared with a conservative “watch and measure” strategy, and assessed safety and functional outcome of these 2 treatment strategies.

Methods: This is a post hoc analysis in 2 randomized controlled stroke trials, the PRACTISE (Promoting Acute Thrombolysis in Ischemic Stroke) and the PASS (Preventive Antibiotics in Stroke Study). We included all patients with elevated pretreatment blood pressure above 185/110 mm Hg at presentation but otherwise eligible for IV thrombolysis (IVT). The decision to use an active or conservative strategy was in accordance with local hospital treatment guidelines. The primary outcome was the proportion of patients treated with IVT. Secondary outcomes were (1) symptomatic intracranial hemorrhage (increased neurologic deficit with a concomitant hemorrhage on neuroimaging), (2) functional outcome at 3 months, and (3) the door-to-needle time.

Results: We included 224 patients, 66 (29%) received the active and 158 (71%) the conservative strategy. In the active group, 55 patients (83%) received thrombolytics vs 87 (55%) in the conservative group, an increase of 28% (95% confidence interval: 16%–40%). If only patients actually treated with IVT were considered, the rate of symptomatic intracranial hemorrhage was 7% in both groups. There was no difference in door-to-needle time.

Conclusions: Active blood pressure lowering was associated with an increased proportion of patients treated with IVT compared with a conservative strategy, without a difference in symptomatic hemorrhage rate.