Seorang rekan residen neuro sampai mengirim (via e-mail) sebuah jurnal yang baru ditelaahnya di larut malam. Kepada si cip, dia menyatakan bagaimana jurnal ini membuat pikirannya bergejolak, “Seperti dipaksa untuk menerima sebuah pemikiran baru yang melawan apa yang telah kita yakini bersama dalam proses belajar kita selama 5 tahun terakhir ini!” Artikel itu berjudul Effect of Blood Pressure Lowering in Early Ischemic Stroke: Meta-Analysis oleh Lee et al., dan dipublikasi dalam jurnal Stroke Juli 2015.

1. Effect of Blood Pressure Lowering in
Early Ischemic Stroke
Time to Change Practice?
Ersifa Fatimah | Surabaya | 2016

2. Early Blood Pressure Reduction After an Acute Ischemic Stroke | Aiyagari, V., 2011.
Pro
•High BP associated with mortality
•Decrease hemorrhagic transformation (especially after thrombolytic
use)
•Decrease cerebral edema
•Indicated for other medical reasons (e.g., myocardial infarction)
•Patients might be more compliant with the use of antihypertensives
if started in the hospital
•Pilot trial data from recent trials suggest that lowering BP acutely is
safe ?
Con
•Chronic hypertensives may develop cerebral ischemia due to shift of the
autoregulatory curve
•Cerebral ischemia might be exacerbated by lowering BP due to impaired
autoregulation in ischemic areas
•Risk of converting ischemic areas to irreversible infarction
•BP decreases spontaneously in the first week, even without treatment
•Decreased perfusion distal to a large-vessel stenosis might be worsened
•Lowering blood pressure might exacerbate or propagate intravascular thrombus
•Case reports of neurological worsening after BP reduction
•No convincing trial data to support acute BP reduction ?

4. Characteristics of Included Trials
(Lee et al., 2015)

5. Characteristics of Included Trials
(Lee et al., 2015)

6. Relative risk with 95% confidence interval (CI) estimates for death or dependency (early blood pressure
lowering vs control) at 3 months or at trial end point among patients with ischemic stroke. (Lee et al., 2015)

7. Guidelines for the Early Management of Patients with Acute Ischemic Stroke, AHA/ASA |
Jauch et al. | 2013

8. Blood Pressure & Stroke Prevention
Primary Prevention
Secondary Prevention
Guidelines for the Primary Prevention of
Stroke, AHA/ASA | Meschia et al. | 2014
Guidelines for the Prevention of Stroke in Patients With Stroke
and Transient Ischemic Attack, AHA/ASA | Kernan et al. | 2014

9. Critiques • Late recruitment (many hours after
stroke onset)
• Smaller BP difference between the
intervention and control arms
• Why neutral result?
(little influence on prognosis? not
best strategy/ methods? harmful to
subgroup of patients?)

10. Elevated Blood Pressure
Ischaemic vs Haemorrhagic
Mechanism  Management
The mechanisms implicated for elevated BP
include pre-existing hypertension, activation of
neuro-endocrine systems, stress of
hospitalisation, infarct topography, stroke
subtype, stroke severity, raised intracranial
pressure

11. What is the
best blood-pressure strategy
in acute ischaemic stroke?
• BP lowering in patients with thrombolysis therapy vs
non-thrombolysis?
• the optimal target of BP lowering?
• the best drug selection?
• the best time to start lowering BP?
• the severity of stroke play a role?

12. New trend for BP management?

13. References
• Lee, M., Ovbiagele, B., Hong, K.S., Wu, Y.L., Lee, J.E., Rao, N.M., Feng, W. and
Saver, J.L., 2015. Effect of Blood Pressure Lowering in Early Ischemic Stroke
Meta-Analysis. Stroke, 46(7), pp.1883-1889.
• Jauch, E.C., Saver, J.L., Adams, H.P., Bruno, A., Demaerschalk, B.M., Khatri, P.,
McMullan, P.W., Qureshi, A.I., Rosenfield, K., Scott, P.A. and Summers, D.R.,
2013. 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, 44(3), pp.870-947.
• Kernan, W.N., Ovbiagele, B., Black, H.R., Bravata, D.M., Chimowitz, M.I.,
Ezekowitz, M.D., Fang, M.C., Fisher, M., Furie, K.L., Heck, D.V. and Johnston,
S.C.C., 2014. Guidelines for the prevention of stroke in patients with stroke
and transient ischemic attack a guideline for healthcare professionals from
the American Heart Association/American Stroke Association. Stroke, 45(7),
pp.2160-2236.
• Meschia, J.F., Bushnell, C., Boden-Albala, B., Braun, L.T., Bravata, D.M.,
Chaturvedi, S., Creager, M.A., Eckel, R.H., Elkind, M.S., Fornage, M. and
Goldstein, L.B., 2014. Guidelines for the Primary Prevention of Stroke A
Statement for Healthcare Professionals From the American Heart
Association/American Stroke Association. Stroke, 45(12), pp.3754-3832
• Aiyagari, V., 2011. Acute Blood Pressure Management After Ischemic Stroke.
In Hypertension and Stroke (pp. 115-126). Humana Press..
• Martins, A.I., Sargento-Freitas, J., Silva, F., Jesus-Ribeiro, J., Correia, I., Gomes,
J.P., Aguiar-Gonçalves, M., Cardoso, L., Machado, C., Rodrigues, B. and Santo,
G.C., 2016. Recanalization Modulates Association Between Blood Pressure
and Functional Outcome in Acute Ischemic Stroke. Stroke,47(6), pp.1571-
1576.

14. END.
Discussion