Early antihypertensive therapy in acute ischemic stroke: A Meta-analysis of randomized controlled trials

Objective: To evaluate whether early initiation of antihypertensive therapy (AHT) improves clinical outcomes in acute ischemic stroke (AIS) compared with placebo or usual care. Methods: We systematically searched PubMed, Embase, and Cochrane CENTRAL for randomized controlled trials (RCTs) evaluating early AHT, defined as blood pressure-lowering treatment initiated within 48 h of symptom onset. Primary outcomes were all-cause mortality and death or functional dependency (modified Rankin Scale score ≥ 3). Secondary outcomes included major vascular events, recurrent stroke, and blood pressure (BP) changes. Pooled risk ratios (RRs) and mean differences (MDs) were estimated using random-effects models. Results: Seven RCTs including 15,521 patients were analyzed. Early AHT was not associated with significant differences in all-cause mortality (RR, 0.97; 95% CI, 0.71–1.31), death or functional dependency (RR, 1.01; 95% CI, 0.92–1.12), major vascular events (RR, 0.89; 95% CI, 0.63–1.26), or recurrent stroke (RR, 0.90; 95% CI, 0.49–1.64). Therapy lowered BP at 24 h (systolic BP: MD, −8.58 mmHg; 95% CI, −9.87−−7.30; diastolic BP: MD, −4.00 mmHg; 95% CI, −4.45−−3.54). Conclusion: In AIS, early AHT produces short-term BP reduction but was not associated with improvement in functional outcomes, mortality, or recurrent stroke. These findings do not support routine early BP lowering in the general AIS population not undergoing reperfusion therapy and reinforce the need for individualized hemodynamic management strategies. © 2026