Routine blood pressure lowering should not be recommended in acute stroke

Blood pressure lowering in the acute phase of stroke has no beneficial effect and should not be included in routine clinical practice, according to the research of Mirza Jusufovic. Instead, such treatment could potentially be harmful in spesific subgroups of stroke.


  1. Compared to placebo, lowering of high blood pressure with candesartan in the acute phase showed no effect on cardiovascular events in neither hemorrhagic stroke nor in stroke patients with carotid artery stenosis. Candesartan, however, reduced functional outcome after six months.
  2. For functional outcome there was a significant trend toward a better effect of candesartan in patients with larger infarcts than in patients with lacunar infarctions.
  3. Patients treated with candesartan within six hours of onset of stroke symptoms, had reduced risk of vascular events during 6-month follow-up.


Thesis: Effects of blood pressure lowering treatment in different subtypes of patients with acute stroke. Results from the Scandinavian Candesartan Acute Stroke Trial
Candidate: Mirza Jusufovic
Time: August 30, 2017 at 13:15
Place: Oslo University Hospital, Rikshospitalet B: Seminar room 2 (B2.U002)
Link to university website (in Norwegian)


High blood pressure in the acute phase of stroke is associated with a poor prognosis and increased risk of hemorrhage or edema. However, blood pressure lowering treatment may reduce blood flow to an infarcted brain even further. The Scandinavian Candesartan Acute Stroke Trial (SCAST) showed no beneficial clinical effects of blood pressure lowering with candesartan in the acute phase of stroke. Treatment was initiated within 30 hours of stroke onset and given for 7 days to a total of 2029 acute stroke patients with systolic blood pressure ≥140 mmHg.

(1) In the 274 patients with hemorrhagic stroke, there was no association between treatment with candesartan and risk of vascular death, stroke or myocardial infarction within 6 months. Candesartan increased the risk of adverse functional outcome by 61 %, a result that needs to be verified in larger studies.

(2) Candesartan did not affect the vascular end point nor functional outcome in the analysis of 187 patients with moderate or severe carotid artery stenosis. However, patients with severe stenosis treated with candesartan were at particularly high risk of stroke progression and poor functional outcome.

(3) For functional outcome, the 510 patients presenting with lacunar infarctions had worse effect of candesartan treatment than the 979 patients with larger infarcts. For the vascular end point, there were no differences in treatment effect.

(5) When candesartan was given within six hours of symptom onset, the treatment reduced the risk of vascular events by 63 % compared to placebo. The effect was only significant in patients with ischemic stroke. The results are based on a new method for analysis of vascular events, and confirm previous analyses from SCAST.

(4) Furthermore, Jusufovic and colleges recently published a review of the current knowledge regarding the management of raised blood pressure in patients with acute stroke. They conclude that overall, blood pressure lowering in the acute phase of ischemic stroke should not be included in routine clinical practice apart from when treating patients with very raised blood pressure or eligible for thrombolytic treatment. In contrast, patients with intracerebral hemorrhage can benefit from blood pressure lowering during the first few hours.


(1) Jusufovic, M., Sandset, E. C., Bath, P. M., & Berge, E. (2014). Blood Pressure–Lowering Treatment With Candesartan in Patients With Acute Hemorrhagic StrokeStroke45(11), 3440-3442.

(2) Jusufovic, M., Sandset, E. C., Bath, P. M., Karlson, B. W., & Berge, E. (2015). Effects of blood pressure lowering in patients with acute ischemic stroke and carotid artery stenosisInternational Journal of Stroke10(3), 354-359.

(3) Sandset, E. C., Jusufovic, M., Sandset, P. M., Bath, P. M., & Berge, E. (2015). Effects of Blood Pressure–Lowering Treatment in Different Subtypes of Acute Ischemic StrokeStroke46(3), 877-879.

(4) Jusufovic, M., K Mishra, N., G Lansberg, M., M Bath, P., Berge, E., & Sandset, E. C. (2016). Blood pressure management in acute strokeCurrent hypertension reviews12(2), 121-126.

(5) Jusufovic, M., Sandset, E. C., Bath, P. M., Berge, E., & Scandinavian Candesartan Acute Stroke Trial (SCAST) Study Group. (2016). Early blood pressure lowering treatment in acute stroke. Ordinal analysis of vascular events in the Scandinavian Candesartan Acute Stroke Trial (SCAST)Journal of hypertension34(8), 1594-1598.

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