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• W2949274089 abstract "HomeStrokeVol. 50, No. 7Letter by Mulder et al Regarding Article, “2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: a Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Mulder et al Regarding Article, “2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: a Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association” Maxim J.H.L. Mulder, MD, PhD Hester F. Lingsma, PhD Diederik W.J. Dippel, MD, PhD Maxim J.H.L. MulderMaxim J.H.L. Mulder Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands Search for more papers by this author Hester F. LingsmaHester F. Lingsma Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands Search for more papers by this author Diederik W.J. DippelDiederik W.J. Dippel Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands Search for more papers by this author Originally published10 Jun 2019https://doi.org/10.1161/STROKEAHA.118.021270Stroke. 2019;50:e211Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: June 10, 2019: Ahead of Print To the Editor:We thank Powers et al1 for yet again a timely and concise update of the guidelines for early ischemic stroke management: “2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: a Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association,” which we expect to be very helpful for stroke physicians inside and outside the United States. Nevertheless, we have a concern about the recommendations regarding blood pressure (BP). In section 3.2, the authors state that “until additional data become available, in patients for whom intraarterial therapy is planned and who have not received intravenous thrombolytic therapy, it is reasonable to maintain BP ≤185/110 mm Hg before the procedure.” Although it is not explicitly stated, this recommendation implies that patients with BP >185/110 mm Hg should be acutely treated with BP-lowering drugs until BP reaches ≤185/110 or endovascular treatment (EVT) should be withheld in these patients.We think both options could be potentially harmful. Lowering BP takes valuable time and as was already stated in 1993: “Time is brain!”2 This was also emphasized by the current guideline update, “… any cause for delay to mechanical thrombectomy, including observing for a clinical response after intravenous alteplase, should be avoided.”1 Second, it is true that there is no convincing evidence of EVT benefit and safety in high BP patients, because most randomized controlled trials that demonstrated the benefit of EVT excluded patients with a BP >185/110 mm Hg. On the contrary, there is also no evidence that EVT is of no benefit or unsafe in these patients; an interaction of BP with EVT has never been demonstrated.3 This is consistent with intravenous thrombolysis, where it is also known that BP does not affect treatment effectiveness or safety.4 The fact that no interaction is found with both acute reperfusion therapies emphasizes that BP in acute ischemic stroke can be considered a prognostic factor for outcome but not a predictive factor that influences the relative effect of intravenous thrombolysis or EVT. Therefore, the available data provide no rationale for a BP threshold. Lastly, acutely lowering BP in ischemic stroke patients with proximal vessel occlusion could also be harmful, as recently stated by Fischer and Mattle in this journal: “rapid BP lowering could compromise blood flow at a time when perfusion is already compromised. Furthermore, in ischemic stroke with persistent vessel occlusion lowering of BP is likely to decrease collateral flow. Because BP autoregulation is disturbed, BP lowering would reduce penumbral perfusion, which could accelerate loss of penumbral tissue and increase the core of the infarct rapidly.”5In conclusion, considering the available evidence, the recommendation regarding high BP management in EVT candidates should be as follows: “There is no evidence to delay or withhold EVT in patients with high BP.”Maxim J.H.L. Mulder, MD, PhDDepartment of NeurologyErasmus MC University Medical CenterRotterdam, the NetherlandsHester F. Lingsma, PhDDepartment of Public HealthErasmus MC University Medical CenterRotterdam, the NetherlandsDiederik W.J. Dippel, MD, PhDDepartment of NeurologyErasmus MC University Medical CenterRotterdam, the NetherlandsDisclosuresDr Dippel reports grants from the Dutch Heart Foundation, the Dutch Brain Foundation, AngioCare, Medtronic/Covidien/EV3, MEDAC Gmbh/LAMEPRO, Penumbra, Top Medical/Concentric, and Stryker during conduct of the study and consultation fees from Stryker, Bracco Imaging, and Servier, received by the Erasmus University Medical Centre, outside the submitted work. The other authors report no conflicts.FootnotesGuest Editor for this article was James C. Grotta, MD.Stroke welcomes Letters to the Editor and will publish them, if suitable, as space permits. Letters must reference a Stroke published-ahead-of-print article or an article printed within the past 4 weeks. The maximum length is 750 words including no more than 5 references and 3 authors. Please submit letters typed double-spaced. Letters may be shortened or edited.References1. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al; American Heart Association Stroke Council. 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for Healthcare Professionals From the American Heart Association/American Stroke Association.Stroke. 2018; 49:e46–e110. doi: 10.1161/STR.0000000000000158LinkGoogle Scholar2. Gomez CR. Editorial: time is brain!J Stroke Cerebrovasc Dis. 1993; 3:1–2. doi: 10.1016/S1052-3057(10)80125-9CrossrefMedlineGoogle Scholar3. Mulder MJHL, Ergezen S, Lingsma HF, Berkhemer OA, Fransen PSS, Beumer D, et al; Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands (MR CLEAN) Investigators. Baseline blood pressure effect on the benefit and safety of intra-arterial treatment in MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands).Stroke. 2017; 48:1869–1876. doi: 10.1161/STROKEAHA.116.016225LinkGoogle Scholar4. Berge E, Cohen G, Lindley RI, Sandercock P, Wardlaw JM, Sandset EC, et al. Effects of blood pressure and blood pressure-lowering treatment during the first 24 hours among patients in the third international stroke trial of thrombolytic treatment for acute ischemic stroke.Stroke. 2015; 46:3362–3369. doi: 10.1161/STROKEAHA.115.010319LinkGoogle Scholar5. Fischer U, Mattle HP. Blood pressure in acute stroke: still no answer for management.Stroke. 2017; 48:1717–1719. doi: 10.1161/STROKEAHA.117.017228LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Anadani M, Lapergue B, Blanc R, Kyheng M, Labreuche J, Machaa M, Duhamel A, Marnat G, Saleme S, Costalat V, Bracard S, Anxionnat R, Spiotta A, DeHavenon A, Richard S, Desal H, Mazighi M, Consoli A, Piotin M and Gory B (2020) Admission Blood Pressure and Outcome of Endovascular Therapy: Secondary Analysis of ASTER Trial, Journal of Stroke and Cerebrovascular Diseases, 10.1016/j.jstrokecerebrovasdis.2020.105347, 29:12, (105347), Online publication date: 1-Dec-2020. July 2019Vol 50, Issue 7 Advertisement Article InformationMetrics © 2019 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.118.021270PMID: 31177987 Originally publishedJune 10, 2019 PDF download Advertisement SubjectsHigh Blood PressureIschemic StrokeRevascularization" @default.
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