Lit Matters 3: Early versus delayed antihypertensive treatment in ischemic stroke

Acute ischemic stroke management prioritizes reperfusion, not early blood pressure reduction, in patients without extreme hypertension. In CATIS-2, starting antihypertensives within 24-48 hours did not improve 90-day death or functional dependence, reinforcing that sustained control matters more than immediate treatment.

Blood Pressure Timing in Ischemic Stroke

• Reperfusion before pressure lowering: In acute ischemic stroke, the priority is thrombolysis or thrombectomy when indicated; antihypertensive therapy is secondary unless blood pressure reaches clearly dangerous extremes.
• CATIS-2 main finding: Early antihypertensive treatment begun within 24-48 hours did not improve the 90-day composite of death or functional dependence compared with waiting to restart therapy later.
• Mild signal toward harm: The early-treatment group had a numerically higher rate of poor 90-day outcome, with a number needed to harm of 65, though the difference was not statistically significant.
• Low severity study population: The median NIHSS was 3, so these results mainly inform mild acute ischemic stroke rather than large-vessel occlusion, severe deficits, or patients headed to thrombectomy.
• Sustained control over urgency: The practical takeaway is that smooth long-term blood pressure control matters more than pushing medications immediately in the first week after uncomplicated ischemic stroke. We get into the bedside implications in the episode.