ISRCTN ISRCTN99414122
DOI https://doi.org/10.1186/ISRCTN99414122
EudraCT/CTIS number 2004-003870-27
ClinicalTrials.gov number NCT00989716
Secondary identifying numbers N/A
Submission date
12/11/2002
Registration date
12/11/2002
Last edited
31/07/2017
Recruitment status
No longer recruiting
Overall study status
Completed
Condition category
Circulatory System
Prospectively registered
Protocol
Statistical analysis plan
Results
Individual participant data

Plain English summary of protocol

Background and study aims
Lowering blood pressure reduces the risk of further strokes in patients who have already had one or more strokes. High blood pressure is common in the first hours and days following a stroke and increases the risk of the patient not recovering fully and being left with some disability. Lowering blood pressure in the first hours and days after stroke with medications might help patients to recover. Although at present we routinely treat high blood pressure long term after a stroke, we do not do so immediately after the stroke. We aim to find out what effect glyceryl trinitrate (or GTN) has on how well people recover from strokes. GTN is a tried and tested drug used in other medical conditions that acts quickly to relax blood vessels and lower blood pressure. The data will help doctors decide whether blood pressure lowering treatments like GTN can be used in patients with acute stroke to improve recovery. We also aim to assess whether or not usual blood pressure medicines should be stopped or continued for 7 days after a stroke.

Who can participate?
Adult (age > 18 years) patients presenting with an acute stroke syndrome with residual motor weakness within 48 hours of onset

What does the study involve?
Patients are randomly allocated to receive either transdermal glyceryl trinitrate patches (GTN) or no GTN for 7 days. Patients who are already receiving blood pressure lowering treatments are also randomly allocated to either continue or stop this treatment for 7 days.

What are the possible benefits and risks of participating?
Participation in the study may reduce the symptoms of the stroke or improve long-term recovery. The information received from patients’ involvement may benefit other people who may have a stroke in the future. All drugs have the possibility of side effects. The side effects from GTN are generally mild. They can include headache, low blood pressure and dizziness.

Where is the study run from?
The University of Nottingham (UK)

When is the study starting and how long is it expected to run for?
January 2004 to October 2013

Who is funding the study?
Medical Research Council (UK)

Who is the main contact?
Prof. Philip Bath
enos@nottingham.ac.uk

Study website

Contact information

Prof Philip Bath
Scientific

Stroke, Division of Clinical Neuroscience, School of Medicine
University of Nottingham
City Hospital Campus
Nottingham
NG5 1PB
United Kingdom

Phone +44 (0)115 823 1768
Email enos@nottingham.ac.uk

Study information

Study designProspective international multicentre randomised parallel-group double-blind placebo-controlled trial
Primary study designInterventional
Secondary study designRandomised controlled trial
Study setting(s)Hospital
Study typeTreatment
Participant information sheet Patient information can be found at: http://www.enos.ac.uk/enospisv211.pdf
Scientific titleA prospective, collaborative, international, multicentre, randomised, parallel-group, single and outcome blinded, controlled, factorial trial to investigate the safety and efficacy of treatment with transdermal glyceryl trinitrate, a nitric oxide donor, and of continuing or stopping temporarily pre-stroke antihypertensive therapy, in patients with acute stroke
Study acronymENOS
Study objectivesThree-quarters of patients are hypertensive at the presentation of acute stroke while a high blood pressure is independently associated with a poor outcome. No large trials have specifically assessed whether blood pressure should be actively altered during the acute phase of stroke although outcome was worse in some trials of calcium channel blockers and beta receptor antagonists, probably through negative effects on cerebral blood perfusion and cardiac output. However, small studies involving drugs from other antihypertensive classes, including nitric oxide donors, suggest they may reduce blood pressure without reducing cerebral blood flow. Similarly, no studies have assessed whether prior anti-hypertensive medication should be stopped or continued. A definitive trial is now required to:
1. Assess the balance of risk and benefit of lowering blood pressure immediately after ischaemic and haemorrhagic stroke.
2. Assess whether prior antihypertensive therapy should be continued or stopped temporarily after stroke.

Protocol can be found at: http://www.enos.ac.uk/enosprotocolv15.pdf

Further reading (added 28/01/2010):
1. The NeuroGrid stroke exemplar clinical trial protocol.
Wardlaw JM et al. International Journal of Stroke 2007;2:63-69
http://www.ncbi.nlm.nih.gov/pubmed/18705995
2. Effect of nitric oxide donors on blood pressure and pulse pressure in acute and subacute stroke.
Gray LJ et al. International Journal of Stroke 2007;2:63-69
http://www.ncbi.nlm.nih.gov/pubmed/17904083
3. Management of blood pressure in acute stroke.
Phillips at al. Canadian J Neurological Sciences 2002;29;404
http://www.ncbi.nlm.nih.gov/pubmed/12463498
4. ENOS Efficacy of Nitric Oxide in Stroke Trial.
Stroke Center Stroke Trials Registry (2002)
http://www.strokecenter.org/trials/TrialDetail.aspx?tid=103
Ethics approval(s)Trent Regional Ethics Committee (REC) and the National Research Ethics Service (NRES), 03/09/2001, ref: MREC/01/4/046
Health condition(s) or problem(s) studiedAcute stroke
Intervention1. Glyceryl trinitrate (transdermal)
2. Continue/temporarily stop prior anti-hypertensive therapy
Intervention typeDrug
Pharmaceutical study type(s)
PhaseNot Applicable
Drug / device / biological / vaccine name(s)Glyceryl trinitrate
Primary outcome measureDeath and dependency (Rankin score more than two).
Secondary outcome measures1. Events by 7 days - recurrent stroke, symptomatic deep vein thrombosis, symptomatic pulmonary embolism, blood pressure daily between 1 and 7 days
2. Hospital events - length of stay in hospital, discharge disposition (death, institution or home)
3. Outcome at 90 days - Barthel Index (less than 60, including death), Barthel Index more than 95/100 at three months (good outcome), quality of life (EuroQol), abbreviated mental test score
4. Safety measures - death at 7 and 90 days, symptomatic intracranial haemorrhage at 7 days, major extracranial haemorrhage at 10 days
Overall study start date01/01/2004
Completion date31/10/2013

Eligibility

Participant type(s)Patient
Age groupAdult
SexBoth
Target number of participants3500+
Key inclusion criteria1. Patients with acute ischaemic or haemorrhagic stroke within 48 hours
2. Systolic blood pressure 140-220 mmHg
Key exclusion criteria1. Unconscious (Glasgow Coma Scale less than eight)
2. Definite need for nitrate therapy: concurrent myocardial infarction, unstable angina, left ventricular failure
3. Dehydration
4. Contraindication to nitrate therapy: hypersensitivity to nitrates, hypovolaemia, hypertrophic obstructive cardiomyopathy, aortic stenosis, cardiac tamponade, constrictive pericarditis, mitral stenosis, marked anaemia, closed-angle glaucoma, sildenafil (Viagra) within previous 24 hours
5. Systolic blood pressure less than 140 mmHg or more than 220 mmHg
6. Patients expected to require surgical intervention (e.g. clot evacuation, carotid endarterectomy) during the treatment or follow-up period
7. Refusal to consent
8. Patient dependent on others prior to stroke (e.g. Rankin score more than three)
9. Known intracerebral pathology other than ischaemic stroke, e.g. subarachnoid haemorrhage, brain tumour, cerebral abscess
10. Other serious condition which is likely to prevent outcome assessment, e.g. advanced cancer
11. Involvement in a trial of another experimental intervention (drug or surgery) for acute stroke
12. Not available for follow-up, e.g. no fixed address, overseas visitor
13. Females of childbearing potential, pregnancy or breastfeeding
Date of first enrolment01/01/2004
Date of final enrolment31/10/2013

Locations

Countries of recruitment

  • Australia
  • Canada
  • China
  • Denmark
  • Egypt
  • England
  • Georgia
  • Greece
  • Hong Kong
  • India
  • Ireland
  • Italy
  • Malaysia
  • New Zealand
  • Norway
  • Philippines
  • Poland
  • Romania
  • Singapore
  • Spain
  • Sri Lanka
  • Sweden
  • Türkiye
  • United Kingdom

Study participating centre

University of Nottingham
Nottingham
NG5 1PB
United Kingdom

Sponsor information

University of Nottingham (UK)
University/education

University Park
Nottingham
NG7 2RD
England
United Kingdom

Website http://www.nottingham.ac.uk/SCS/Divisions/Stroke/index.aspx
ROR logo "ROR" https://ror.org/01ee9ar58

Funders

Funder type

Charity

Medical Research Council: from 01/112006
Government organisation / National government
Alternative name(s)
Medical Research Council (United Kingdom), UK Medical Research Council, MRC
Location
United Kingdom
Singapore A*STAR (MRI sub-study)

No information available

Bupa Foundation: 01/042004 - 31/10/2006
Private sector organisation / Trusts, charities, foundations (both public and private)
Location
United Kingdom
Medical Research Council (as part of NeuroGRID)
Government organisation / National government
Alternative name(s)
Medical Research Council (United Kingdom), UK Medical Research Council, MRC
Location
United Kingdom
Hypertension Trust: 01/09/2002 - 31/08/2004
Private sector organisation / Other non-profit organizations
Location
United Kingdom
UK Reichstadt bequest

No information available

Stroke Association
Private sector organisation / Associations and societies (private and public)
Location
United Kingdom
University of Nottingham
Private sector organisation / Universities (academic only)
Location
United Kingdom

Results and Publications

Intention to publish date
Individual participant data (IPD) Intention to shareNo
IPD sharing plan summaryNot provided at time of registration
Publication and dissemination planNot provided at time of registration
IPD sharing plan

Study outputs

Output type Details Date created Date added Peer reviewed? Patient-facing?
Abstract results 01/01/2005 No No
Protocol article protocol 01/11/2006 Yes No
Interim results article interim results 01/02/2009 Yes No
Results article results 01/03/2013 Yes No
Results article results 01/12/2013 Yes No
Statistical Analysis Plan statistical analysis plan 01/04/2014 No No
Other publications patient baseline characteristics 01/08/2014 Yes No
Results article results 14/02/2015 Yes No
Results article results 01/11/2015 Yes No
Results article results 01/01/2016 Yes No
Results article results 01/12/2017 Yes No

Editorial Notes

31/07/2017: Publication reference added.

19/06/2014: The following changes were made to the trial record:
1. The scientific title was added.
2. Denmark, Republic of Ireland, Georgia, Greece, Norway, Sweden and Turkey were added to the countries of recruitment and Belgium and Saudi Arabia were removed.
3. The target number of participants was changed from 5000 to 3500+.

01/02/2010: The overall trial end date was changed from 31/10/2011 to 31/10/2013.

28/01/2010: The following countries of recruitment were added: Egypt, India, Malaysia, Romania, Saudi Arabia, Spain, and Sri Lanka.