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Page 16 of 20 Akinci et al. Vessel Plus 2021;5:56 https://dx.doi.org/10.20517/2574-1209.2021.20

ENOS trial, a subset of patients who were taking antihypertensive drugs before their stroke were randomly
assigned to either continue or stop taking these drugs, and no evidence was found to support continuing
[64]
pre-stroke antihypertensive drugs in the first few days . To date, there is no evidence to support
continuing or discontinuing pre-stroke antihypertensive drugs in patients within the first few days after
ICH. However, even if they are discontinued, oral antihypertensive agents should be started as soon as
possible (preferably 24 to 48 h after symptom onset, because most of the acute processes are uncommon
after the first 24 h) to control resistant hypertension and facilitate the transition to long-term management
for secondary prophylaxis.

CONCLUSION
While current trials have shown that intensive BP lowering is clinically feasible and potentially safe, the
treatment threshold, BP target, therapeutic window, medications to be used and whether such treatment
improves clinical outcomes remain unclear. Current guidelines cannot provide clear answers to these
uncertainties. Almost all randomized clinical trials included patients receiving anticoagulant or antiplatelets
3
with different rates and different criteria (while a platelet count < 100.000 mm was required to be included
3
in the ATACH study, < 50.000 mm was required in the ATACH-2 study; while international normalize
ratio < 1.8 was required to include patients receiving warfarin in the study of Koch et al. , < 1.4 was
[52]
required in the ATACH study, etc). The small sample sizes and heterogeneous criteria make it difficult to
understand whether we should make individual changes in the treatment of these patients’ acute
hypertensive response [48,52,58] . The safety of the current SBP reduction therapies in patients with severe
disease, large hematomas, ICP elevation, and impaired cerebral perfusion pressure is unknown as they were
not represented in clinical trials. The therapeutic target for SBP lowering may vary between individual
patients, depending on individual cerebral hemodynamics. An example is the investigation of the safety and
[50]
effectiveness of intensive BP lowering in ICH patients with cerebrovascular stenosis . The results of future
studies may reveal the need for an individualized treatment with CBF and regional ICP measurements.

DECLARATIONS
Authors’ contributions
Wrote the first draft of the manuscript: Akinci Y
Discussed the results and commented on the manuscript at all stages: Qureshi AI
Read and approved the final manuscript: Akinci Y, Qureshi AI

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
Both authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not applicable.