Summary Background Raised blood pressure is common after acute stroke and is associated with an adverse prognosis. We sought to assess the feasibility, safety, and effects of two regimens for ...lowering blood pressure in patients who have had a stroke. Methods Patients who had cerebral infarction or cerebral haemorrhage and were hypertensive (systolic blood pressure SBP >160 mm Hg) were randomly assigned by secure internet central randomisation to receive oral labetalol, lisinopril, or placebo if they were non-dysphagic, or intravenous labetalol, sublingual lisinopril, or placebo if they had dysphagia, within 36 h of symptom onset in this double-blind pilot trial. The doses were titrated up if target blood pressure was not reached. Analysis was by intention to treat. This trial is registered with the National Research Register, number N0484128008. Findings 179 patients (mean age 74 SD 11 years; SBP 181 SD 16 mm Hg; diastolic blood pressure DBP 95 SD 13 mm Hg; median National Institutes of Health stroke scale NIHSS score 9 IQR 5–16 points) were randomly assigned to receive labetolol (n=58), lisinopril (n=58), or placebo (n=63) between January, 2005, and December, 2007. The primary outcome—death or dependency at 2 weeks—occurred in 61% (69) of the active and 59% (35) of the placebo group (relative risk RR 1·03, 95% CI 0·80–1·33; p=0·82). There was no evidence of early neurological deterioration with active treatment (RR 1·22, 0·33–4·54; p=0·76) despite the significantly greater fall in SBP within the first 24 h in this group compared with placebo (21 17–25 mm Hg vs 11 5–17 mm Hg; p=0·004). No increase in serious adverse events was reported with active treatment (RR 0·91, 0·69–1·12; p=0·50) but 3-month mortality was halved (9·7% vs 20·3%, hazard ratio HR 0·40, 95% CI 0·2–1·0; p=0·05). Interpretation Labetalol and lisinopril are effective antihypertensive drugs in acute stroke that do not increase serious adverse events. Early lowering of blood pressure with lisinopril and labetalol after acute stroke seems to be a promising approach to reduce mortality and potential disability. However, in view of the small sample size, care must be taken when these results are interpreted and further evaluation in larger trials is needed. Funding UK National Health Service Research and Development Health Technology Assessment Programme.
Background Stroke is the second largest cause of death worldwide. Abnormalities in hemostasis play an important role in the pathophysiology of ischemic stroke (IS). These hemostatic defects can be ...detected using rotational thromboelastometry (ROTEM) as a global method of measuring coagulation.This study assessed the effects of IS on blood hypercoagulability using ROTEM method, before and subsequent to therapeutic interventions. Methods In a prospective observational cohort study, whole blood coagulation using ROTEM, along with full blood count and standard coagulation tests, were compared between patients with IS and an age-matched control group of healthy volunteers. Further assessment took place at 2-4 hours and at 24 hours in the stroke group after therapy to assess the effects of therapeutic intervention. Results Seventy-two patients with IS were age-matched to 71 healthy subjects. Clotting time (CT) INTEM ( P = .01) and maximum clot firmness (MCF) INTEM ( P = .02) were significantly different between stroke patients at baseline and healthy subjects, but this difference disappeared when controlled for by smoking status. There was no association between ROTEM parameters and time from stroke symptom onset or stroke severity as reflected in The National Institute of Health Stroke Scale score. Significant but small changes in the values of MCF-EXTEM, clot formation time (CFT) EXTEM, and alpha-EXTEM CT were observed after therapeutic intervention (thrombolysis or aspirin treatment). Conclusions ROTEM testing does not seem to detect a hypercoagulable state in patients with IS. Nonetheless, some ROTEM parameters had a small change after antiplatelet therapy or thrombolysis.
Background Time to computerized tomography (CT) is important to institute appropriate and timely hyperacute management in stroke. We aimed to evaluate mortality outcomes in relation to age and time ...to CT scan. Methods We used routinely collected data in 8 National Health Service trusts in East of England between September 2008 and April 2011. Stroke cases were prospectively identified and confirmed. Odds ratios (ORs) for unadjusted and adjusted models for age categories (<65, 65-74, 75-84, and ≥85 years) as well as time to CT categories (<90 minutes, ≥90 to <180 minutes, ≥180 minutes to 24 hours, and >24 hours) and in-hospital and early (<7 days) mortality outcomes were calculated. Results Of the 7693 patients (mean age 76.1 years, 50% male) included, 1151 (16%) died as inpatients and 336 (4%) died within 7 days. Older patients and those admitted from care home had a significantly longer time from admission until CT ( P < .001). Patients who had earlier CT scans were admitted to stroke units more frequently ( P < .001) but had higher in-patient ( P < .001) and 7-day mortality ( P < .001). Whereas older age was associated with increased odds of mortality outcomes, longer time to CT was associated with significantly reduced mortality within 7 days (corresponding ORs for the above time periods were 1.00, .61 95% confidence interval {CI}: .39-.95, .39 .24-.64, and .16 .08-.33) and in-hospital mortality (ORs 1.00, .86 .64-1.15, .57 .42-.78 and .71 .52-.98). Conclusions Older age was associated with a significantly longer time to CT. However, using CT scan time as a benchmarking tool in stroke may have inherent limitations and does not appear to be a suitable quality marker.
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