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Staff in Internal Medicine

Outcomes are superior in patients with acute stroke from New Zealand versus rest of world: Data from the efficacy of nitric oxide in stroke (ENOS) trial

Furlong, M., Woodhouse, L., Gommans, J., Sprigg, N., & Bath, P. (2016). Internal Medicine Journal, 46, 18–19.


Optimal high blood pressure (BP) management in acute stroke patients remains unclear.


Outcomes differences between countries may reflect systematic differences in care.


ENOS assessed the safety and ef!cacy of trans- dermal glyceryl trinitrate (GTN, 5 mg vs none for 7 days) in 4,011 acute stroke patients (<48 hours of onset) and high blood pressure (systolic BP > 140 mmHg). Patients were recruited from 23 countries, including New Zealand (NZ). Primary outcome was modi!ed Rankin Scale (mRS) measured at day 90. Statistical analysis comparing outcomes between NZ and rest of world (RoW) were adjusted for age, sex, pre-morbid mRS, diabetes, previous stroke, prior nitrate use, stroke type, stroke severity, syndrome, systolic BP, use of alteplase, feeding status, time to randomisation, and treatment assignment.


Although GTN did not alter overall ENOS outcome, patients randomised within 6 hours of onset may have received some benefit from hyper-acute GTN and appear to have an improved mRS. In comparison with 3940 patients from RoW, the 71 NZ patients were more likely to be recruited <6 hours (26.8 vs 6.4%), were older (74.5 vs 70.2 years) and were more likely to have vascular risk factors: hypertension (63.4 vs 53.1%), dia- betes (19.7 vs 17.4%), atrial fibrillation (28.2 vs 18.8%), prior stroke (19.7 vs 14.7%), prior TIA (25.4 vs 13.4%), and ischemic heart disease (33.8 vs 16.4%). NZ patients were less likely to have intracerebral haemorrhage (8.5 vs 16.0%) or total anterior circulation stroke (22.5 vs 30.3%), and were more likely to receive thrombolysis (18.3 vs 10.5%). Day 90 outcomes were better in NZ patients: mRS (median 2 vs 3, 2p = 0.006), Barthel Index (72.2 vs 64.4, 2p = 0.003), EQ-5D Health Utility Status (0.6 vs 0.5, 2p = 0.004), and verbal fluency (11.0 vs 9.2, 2p = 0.008). NZ patients had a shorter hospital stay (6 vs 11 days, 2p < 0.001). Death did not vary between NZ and RoW (12.7% vs 12.4%, 2p = 0.29).


Better outcome in NZ patients may reflect earlier hospital admission, and therefore both greater exposure to GTN within 6 hours and greater use of thrombolysis.


The ENOS Trial Investigators: Efficacy of nitric oxide, with or without continuing antihypertensive treatment, for management of high blood pressure in acute stroke (ENOS): a partial-factorial randomized controlled trial published online October 22, 2014 61121-1 Nikola Sprigg, Lisa Woodhouse, Philip M Bath: International Stroke Meeting 2015 Presentation 156 - Glyceryl Trinitrate for Hyperacute Stroke: Results from the Ef!cacy of Nitric Oxide in Stroke (ENOS) Trial Ankole, Sandeep et al: Feasibility of an Ambulance-Based Stroke Trial, and Safety of Glyceryl Trinitrate in Ultra-Acute Stroke The Rapid Intervention With Glyceryl Trinitrate in Hypertensive Stroke Trial (RIGHT, ISRCTN66434824) 11/3120.full

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