Early Versus Delayed Antihypertensive Therapy in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background and Objectives: Ischemic stroke remains a major global cause of death and morbidity. Hypertension is often found in this condition and is associated with poorer functional outcomes and higher mortality. This study aimed to evaluate the effectiveness of early antihypertensive therapy in acute ischemic stroke. Methods: This study followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. Literature searches in PubMed, the Cochrane Library, and ClinicalTrials.gov from database inception to October 20, 2025 included randomized controlled trials (RCTs) involving adults with ischemic stroke. The primary outcome was mortality; secondary outcomes included functional outcomes measured by the modified Rankin Scale (mRS), major vascular events, and recurrent stroke. Pooled effects were calculated using a random-effects model as an odds ratio with a 95% confidence interval. Heterogeneity was assessed using the I 2 statistic. Results: Three RCTs were included. Early antihypertensive therapy showed no significant difference compared with delayed treatment in mortality or major disability at 90 days, good functional outcome (mRS: 0–2), or poor functional outcome (mRS: 3–6). No significant subgroup differences were observed. Early treatment also did not reduce the risk of major vascular events or recurrent stroke. Conclusions: Current evidence from a limited number of RCTs suggests that early antihypertensive therapy is not associated with improved mortality or major disability at 90 days, functional outcomes, vascular events, or recurrent stroke in patients with ischemic stroke. However, these findings should be interpreted with caution, given the small number of included studies, and further large-scale RCTs are needed.