Hypertension Management in Acute Stroke

The goal of treatment was to reduce and maintain the hourly minimum systolic blood pressure in the range of 140 to 179 mm Hg in the standard-treatment group and in the range of 110 to 139 mm Hg in the intensive-treatment group throughout the period of 24 hours after randomization. Before randomization, intravenous anti-hypertensive medication, including nicardipine, could be administered to lower the systolic blood pressure to less than 180 mm Hg,^{12 (link)} but patients were not eligible if the systolic blood pressure was lowered to less than 140 mm Hg. After randomization, nicardipine, administered by intravenous infusion, was the first-line antihypertensive agent and was initiated at a dose of 5 mg per hour, which was then increased by 2.5 mg per hour every 15 minutes as needed, up to a maximum dose of 15 mg per hour. If the systolic blood-pressure level was higher than the target, despite infusion of the maximum dose of nicardipine for 30 minutes, a prespecified second agent, intravenous labetalol, was used. In countries where labetalol was not available, intravenous diltiazem or urapidil was used. Additional care was based on the best available evidence^{15 (link)} and the guidelines from the American Stroke Association Stroke Council^{12 (link)} and the European Stroke Initiative Writing Committee.^{16 (link)}We assessed the success, or lack thereof, of the reduction in the systolic blood-pressure level. Primary treatment failure was defined as not reaching the target systolic blood pressure of less than 140 mm Hg in the intensive-treatment group and less than 180 mm Hg in the standard-treatment group within 2 hours after randomization. Secondary treatment failure was defined as the hourly minimum systolic blood pressure remaining higher than the upper limit of the target range for 2 consecutive hours during the period of 2 to 24 hours after randomization. No effort was made to conceal the treatment assignment from the participants or treating physicians.