Hypertension and stroke – rationale behind the ACCESS trial

Abstract

Antihypertensive treatment achieves its greatest benefit in the primary prevention of stroke. Primary prevention studies show 38% fewer strokes when systolic/diastolic values are reduced by 10–12/5–6 mmHg. Secondary stroke prevention has been less investigated, but restrokes seems to be reduced with antihypertensive treatment.

Secondary prevention achieves 25–30% less strokes, if diastolic BP can be reduced by 3–4 mmHg. Today's guidelines for antihypertensive therapy in acute ischemic stroke suggest reducing BP values over 220 mmHg systolic (AHA) or 200/110 (German Hypertension Society). No data are available about antihypertensive treatment in acute stroke patients. No intervention trials have so far evaluated an immediate BP reduction on the clinical outcome of patients neurological status (morbidity) or mortality rates in the acute stroke situation. However, some sutdies show an increase in mortality after a quick and rapid BP reduction in a short time interval. The ACCESS study was designed to evaluate the possible benefits of a careful and moderate, but immediate blood pressure reduction in patients with an acute stroke compared to a restrictive antihypertensive therapy. Candesartan cilexetil was selected as the antihypertensive drug for its slow onset of action and moderate BP reduction, as well as its very good tolerability. Experimental studies point at possible advantages in acute stroke. The study was designed as a prospective, randomized, double-blind, placebo-controlled, multicenter trial (500 patients). Inclusion criteria were an acute ischemic stroke with a motor paresis and severe hypertension. Primary endpoints were the patients morbidity (functional status measured with Rankin and Barthel index, degree of motor deficity by NIH scale) and mortality rates after three months. First results are presented.