Pre-hospital blood pressure lowering in presumed hyperacute stroke: A systematic review and meta-analysis of randomized controlled trials

Ahmed A Ibrahim; Yehya Khlidj; Ahmed Mazen Amin; Mohamed Saad Rakab; AlMothana Manasrah; Abdelrahman Mahmoud; Muhammad Imran; Ahmed Gaber Emara; Mohamed Abuelazm

doi:10.1016/j.jstrokecerebrovasdis.2024.108158

Pre-hospital blood pressure lowering in presumed hyperacute stroke: A systematic review and meta-analysis of randomized controlled trials

J Stroke Cerebrovasc Dis. 2024 Nov 28;34(2):108158. doi: 10.1016/j.jstrokecerebrovasdis.2024.108158. Online ahead of print.

Authors

Ahmed A Ibrahim¹, Yehya Khlidj², Ahmed Mazen Amin³, Mohamed Saad Rakab³, AlMothana Manasrah⁴, Abdelrahman Mahmoud⁵, Muhammad Imran⁶, Ahmed Gaber Emara⁷, Mohamed Abuelazm⁸

Affiliations

¹ Faculty of Medicine, Menoufia University, Menoufia, Egypt.
² Faculty of Medicine, Algiers University, Algiers, Algeria.
³ Faculty of Medicine, Mansoura University, Mansoura, Egypt.
⁴ Internal Medicine Department, UHS-Wilson Medical Center, Johnson City, NY, USA. Electronic address: Almothanamanasrah@gmail.com.
⁵ Faculty of Medicine, Minia University, Minia, Egypt.
⁶ University College of Medicine and Dentistry, University of Lahore, Lahore, Pakistan.
⁷ Department of Cardiology, Menoufia University, Menoufia, Egypt.
⁸ Faculty of Medicine, Tanta University, Tanta, Egypt.

PMID: 39615639
DOI: 10.1016/j.jstrokecerebrovasdis.2024.108158

Abstract

Background: High blood pressure (BP) is common in acute stroke and a predictor of poor outcomes. Treatment of acute stroke, before a distinction can be made between ischemic and hemorrhagic types, is challenging. We aimed to assess whether patients with presumed acute stroke benefit from pre-hospital BP lowering.

Methods: We conducted a comprehensive systematic review and meta-analysis of randomized controlled trials from PubMed, Web of Science, Scopus, and Cochrane searches until June 2024. Dichotomous data were pooled using risk ratio (RR), and continuous data were pooled using mean difference (MD), both with a 95% confidence interval (CI), using (R version 4.3).

Prospero id: CRD42024560200.

Results: Our analysis included five RCTs encompassing 3,933 patients. There was no difference between early BP control and usual care regarding National Institutes of Health Stroke Scale (NIHSS) after 24 hours (MD: 0.65 with 95% CI [0.01, 1.29], P = 0.05), excellent neurological recovery (Modified Rankin Score (mRS) 0-1) (RR: 1.00 with 95% CI [0.91, 1.11], P= 0.98), functional independence (mRS 0-2) (RR: 1.04 with 95% CI [0.96, 1.13], P= 0.30), and independent Ambulation (mRS 0-3) (RR: 1.01 with 95% CI [0.95, 1.06], P= 0.84). Also, there was no difference between both groups in poor neurological recovery (mRS 4-6) (RR: 0.98 with 95% CI [0.91, 1.07], P= 0.68), all-cause mortality (RR: 1.02 with 95% CI [0.90, 1.15], P= 0.79), and any serious adverse events (RR: 1.04 with 95% CI [0.95, 1.15], P= 0.40). However, early BP control significantly increased the incidence of hypotension (RR: 2.24 with 95% CI [1.14, 4.38], P= 0.02) and headache (RR: 1.51 with 95% CI [1.01, 2.26], P= 0.04).

Conclusion: In patients with presumed hyperacute stroke and elevated blood pressure, the rapid initiation of blood pressure reduction in the ambulance very early after symptom onset had no significant benefit regarding functional outcomes in patients with undifferentiated stroke but with an increased incidence of hypotension and headaches.

Keywords: BP; Blood pressure; Pre-hospital; Stroke; analysis; review.