Current guidelines only recommend antihypertensive treatment for patients with acute stroke if the blood pressure is significantly elevated. Previous research has suggested that candesartan, an angiotensin-receptor blocker, reduces cardiovascular mortality and morbidity following stroke in patients with hypertension requiring treatment (Stroke 2003 Jul;34(7):1699). In that trial, patients had systolic pressure ? 180 mm Hg and/or diastolic pressure ? 105 mm Hg at 24-36 hours after hospital admission. The recent SCAST trial evaluated the effects of candesartan in 2,009 patients with acute stroke whose blood pressure was raised but not in need of acute treatment. Adult patients with systolic pressure ? 140 mm Hg within 30 hours of acute ischemic or hemorrhagic stroke were randomized to candesartan (4 mg on day 1, 8 mg on day 2, 16 mg on days 3-7) vs. placebo for 7 days. Candesartan during follow-up was at the discretion of the investigator, but candesartan was the advised hypertensive medication. At baseline, median blood pressures were 171 mm Hg (systolic) and 90 mm Hg (diastolic). After 7 days, the candesartan group had significantly reduced blood pressure. However there were no significant differences at 6 months in vascular death (6% vs. 6%), all-cause mortality (8.3% vs. 7.7%), nonfatal stroke (5% vs. 4%) or nonfatal myocardial infarction (1% vs. 1%) (level 1 [likely reliable] evidence). The candesartan group had increased risk of stroke progression (6% vs. 4%, p = 0.04, NNH 50) and of poor function at 6 months (p = 0.048) (Lancet 2011 Feb 26;377(9767):741).
For more information, see the Blood pressure management in acute ischemic stroke topic in DynaMed.