21st European Meeting on Hypertension and Cardiovascular Prevention

Results from the Scandinavian Candesartan Acute Stroke Trial (SCAST), presented by Eivind Berge, MD, Oslo University Hospital, Oslo, Norway, show no benefit and possibly some harm from blood pressure (BP) lowering in the acute phase of stroke.

SCAST is trial of BP lowering with candesartan in subjects aged ≥18 years with acute stroke and systolic (SBP) ≥140 mmHg. Subjects were enrolled within 30 hours of symptom onset and randomly assigned to receive candesartan (n = 1,017; doses increasing from 4- to 16-mg during the first 3 days) or placebo (n = 1,012) for 7 days. The two co-primary endpoints were a composite of vascular death, myocardial infarction (MI) or stroke during the first 6 months and functional outcome at 6 months using the modified Rankin Scale.

Study participants (mean age 70 years, mostly men) had a mean BP of 171/90 mmHg and mean duration of symptoms before randomization of 18 hours. Eighty-five percent of subjects had an ischemic stroke; 14% hemorrhagic stroke. SBP was significantly lower in subjects receiving candesartan (p ≤0.001) beginning on Day 2; however, there was no statistically significant difference between the candesartan (11.7%) and placebo (11.3) groups in the risk of the composite vascular endpoint (Adjusted HR, 1.09; 95% CI, 0.84 to 1.41; p = 0.52). Subjects in the candesartan group were more likely to have a poor functional outcome than those receiving placebo but the difference was not significant (OR, 1.17; 95% CI, 1.00 to 1.38; p = 0.048).

There were no significant differences on any of the secondary endpoints (ie, death from any cause, vascular death, ischemic, hemorrhagic, or recurrent stroke, MI, or stroke progression) and there was no evidence of a differential effect in any of the prespecified subgroups (eg, type of stroke, BP, duration of symptoms, history of hypertension) for either of the two primary effect variables.

In a secondary analysis evaluating the relationship between the change in SBP at day 2 and the risk early adverse events (i.e., stroke recurrence, stroke progression, or symptomatic hypotension during first 7 days) and poor outcome, patients with an increase or large decrease in SBP [>28.5 mmHg] had a higher risk of early adverse events compared with those having only a small decrease in SBP. No association was seen between a decrease in SBP and the risk of poor functional outcome at 6 months. Prof. Berge noted that these results should be taken with caution as they are not randomized and are subject to confounding.

In concluding, Prof. Berge noted that there is no indication for routine BP lowering treatment in patients with acute stroke and elevated BP. Ongoing trials (ENOS, INTERACT2) will help to clarify whether there are subgroups of patients or different approaches to BP lowering management where a treatment benefit can be obtained.