Blood Pressure in Acute Stroke and Its Prognostic Value

To the Editor: We read with interest the recent paper by Castillo and colleagues evaluating the prognostic relevance of admission blood pressure (BP) values and describing a U-shaped effect in patients with acute ischemic stroke, as well as Boysen’s editorial comment on this issue.1,2 The study’s conclusion was that both high and low admission BP values are associated with poor prognosis regarding early neurological deterioration, infarct volume, and mortality at 3 months. After adjustment for the use of antihypertensive drugs and BP drop >20mm Hg, the authors found that the latter was the most important prognostic factor for poor outcome. Before accepting these important conclusions, we think that some comments are needed. We have also evaluated the prognostic value of admission BP values in an unselected collective of acute stroke patients. Our findings demonstrated that early and late mortality in patients with ischemic stroke as well as in patients with intracerebral hemorrhage followed a U-shaped pattern in relation to systolic and diastolic BP at admission.3 Low admission BP values were associated with heart failure and coronary artery disease, whereas high BP values were associated with history of hypertension and lacunar stroke. Death due to cardiovascular disease was significantly more frequent among patients with admission BP values beneath the U-point of 130 mm Hg, whereas death due to brain edema was significantly more frequent above this U-point.3 We also demonstrated by means of 24-hour BP monitoring that persisting elevated systolic 24-hour BP values during the acute phase of stroke are associated with subsequent brain edema formation in patients not receiving antihypertensive medication during the BP monitoring.4 Investigating the relationship …