Degree of blood pressure reduction and recurrent stroke: the PROGRESS trial

Arima, Hisatomi; Anderson, Craig S.; Omae, Teruo; Woodward, Mark; MacMahon, Stephen; Mancia, Giuseppe; Bousser, Marie‐Germaine; Tzourio, Christophe; Harrap, Stephen B; Liu, Lisheng; Neal, Bruce; Chalmers, John

doi:10.1136/jnnp-2014-307856

Cited by 17 publications

(16 citation statements)

References 5 publications

(8 reference statements)

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“…In the group randomised to antihypertensive treatment, the blood pressure reduction was accompanied by a reduction in the risk of stroke recurrence that was significant in both diabetic and in non-diabetic individuals. The benefit in terms of reduction of haemorrhagic stroke was striking (a reduction of 60-80%), and a benefit was also seen for initial SBPs of 120-139 mmHg and achieved SBPs of <120 mmHg [28].…”

Section: Introductionmentioning

confidence: 83%

Blood pressure targets in type 2 diabetes. Evidence against or in favour of an aggressive approach

Mancia

2018

Diabetologia

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When associated with high blood pressure, type 2 diabetes mellitus is characterised by a high risk of adverse cardiovascular (CV) and renal outcomes. However, both can be effectively reduced by antihypertensive treatment. Current guidelines on the treatment of hypertension emphasize the need to effectively treat high blood pressure in diabetic individuals, but their recommendations differ in terms of the optimal target blood pressure value to aim for in order to maximise CV and renal protection. In some guidelines the recommended target blood pressure values are <140/90 mmHg (systolic/diastolic), whereas in others, blood pressure values close or even less than 130/80 mmHg are recommended. This paper will discuss the evidence for and against a conservative or more aggressive blood pressure target for treated diabetic hypertensive individuals based on the evidence provided by randomised trials, trial meta-analyses and large observational studies. Based on the available evidence, it appears that blood pressure targets will probably have to be lower than <140/90 mmHg, and that values approaching 130/80 mmHg should be recommended. However, evidence in favour of even lower systolic values, i.e. <130 mmHg, is limited and is definitively against a reduction to <120 mmHg.

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Section: Introductionmentioning

confidence: 83%

Blood pressure targets in type 2 diabetes. Evidence against or in favour of an aggressive approach

Mancia

2018

Diabetologia

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“…4 However, the benefit and safety of more intensive BP lowering or treatment to lower achieved BP for incident outcomes other than stroke remains uncertain, 4,7-11 with a potential for hazard as noted by the increased mortality risk with lower achieved SBP in the overall LIFE study population 11 and the diabetic subgroup of hypertensive patients with coronary disease participating in the International Verapamil SR-Trandolapril Study (INVEST) study. 9 Although treatment of hypertension in patients after a stroke also reduces the risk of recurrent stroke, [12][13][14][15][16] findings on the effectiveness and safety of a lower achieved SBP or greater BP reduction for optimal prevention of stroke recurrence are less clear and there are only limited data on mortality. [13][14][15][16] Among patients with recent lacunar stroke, randomized treatment to a SBP target of <130 versus 130 to 149 mm Hg was associated with a nonsignificant reduction for all stroke (hazard ratio, 0.81; 95% confidence interval, 0.64-1.03) and no significant change in all-cause mortality during 3.7 years mean follow-up.…”

Section: Discussionmentioning

confidence: 99%

“…9 Although treatment of hypertension in patients after a stroke also reduces the risk of recurrent stroke, [12][13][14][15][16] findings on the effectiveness and safety of a lower achieved SBP or greater BP reduction for optimal prevention of stroke recurrence are less clear and there are only limited data on mortality. [13][14][15][16] Among patients with recent lacunar stroke, randomized treatment to a SBP target of <130 versus 130 to 149 mm Hg was associated with a nonsignificant reduction for all stroke (hazard ratio, 0.81; 95% confidence interval, 0.64-1.03) and no significant change in all-cause mortality during 3.7 years mean follow-up. 14 In a post hoc analysis of the Perindopril Protection Against Recurrent Stroke Study (PROGRESS) trial, 15 adjusted annual incidence of recurrent stroke varied significantly across groups defined by SBP reductions of ≥20, 10 to 19, 0 to 9, and <0 mm Hg, but this was driven primarily by a reduction in intracerebral hemorrhage, with incidence of recurrent stroke of an ischemic cause only weakly related to change in SBP.…”

Section: Discussionmentioning

confidence: 99%

“…[13][14][15][16] Among patients with recent lacunar stroke, randomized treatment to a SBP target of <130 versus 130 to 149 mm Hg was associated with a nonsignificant reduction for all stroke (hazard ratio, 0.81; 95% confidence interval, 0.64-1.03) and no significant change in all-cause mortality during 3.7 years mean follow-up. 14 In a post hoc analysis of the Perindopril Protection Against Recurrent Stroke Study (PROGRESS) trial, 15 adjusted annual incidence of recurrent stroke varied significantly across groups defined by SBP reductions of ≥20, 10 to 19, 0 to 9, and <0 mm Hg, but this was driven primarily by a reduction in intracerebral hemorrhage, with incidence of recurrent stroke of an ischemic cause only weakly related to change in SBP. 15 Importantly, there was no evidence of an increased risk of recurrent stroke associated with larger SBP reductions, but mortality was not examined.…”

Section: Discussionmentioning

confidence: 99%

“…4 In contrast, the relationship between BP and outcomes after a stroke is less clear. Although BP lowering after stroke reduces the risk of recurrent stroke, [12][13][14][15][16] findings on the effectiveness and safety of greater BP reduction or lower achieved SBP for optimal prevention of stroke recurrence are inconclusive, [13][14][15][16] with some data that poststroke average SBP in the very low normal range (<120 mm Hg) may be associated with increased risk of recurrent stroke and death. 16 However, there has been a relative paucity of data on the relationship of lower achieved SBP after stroke to mortality.…”

mentioning

confidence: 99%

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Systolic Blood Pressure Control and Mortality After Stroke in Hypertensive Patients

Okin

Kjeldsen

Devereux

2015

Stroke

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Background and Purpose-Hypertensive patients with electrocardiographic left ventricular hypertrophy are at increased risk of all-cause and cardiovascular death. Lowering blood pressure (BP) after stroke reduces the risk of recurrent stroke, but recent data suggest that lower systolic BP (SBP) measured 5 years after stroke is associated with increased mortality. Whether lower SBP is associated with increased short-term mortality after stroke in hypertensive patients is unclear. Methods-All-cause and cardiovascular mortality were examined in relation to average on-treatment SBP after stroke in 541 hypertensive patients with electrocardiographic left ventricular hypertrophy randomly assigned to losartan-or atenololbased treatment who had new strokes during follow-up. Patients with on-treatment SBP<144 mm Hg (lowest tertile) and SBP>157 (highest tertile) were compared with patients with average SBP between 144 and 157. Results-During 2.02±1.65 years mean follow-up after incident stroke, 170 patients (31.4%) died, 135 (25.0%) from cardiovascular causes. In multivariate Cox analyses, adjusting for significant univariate predictors of mortality, compared with average SBP between 144 and 157, an average SBP<144 was a significant predictor of all-cause (hazard ratio, 1.81; 95% confidence interval, 1.20-2.73) and cardiovascular mortality (hazard ratio, 1.60; 95% confidence interval, 1.02-2.54), whereas patients who had an average SBP>157 had no significant increased risk of death. Conclusions-Lower achieved SBP (<144 mm Hg) is associated with a significantly increased risk of cardiovascular and all-cause mortality after initial stroke in hypertensive patients during short-term follow-up. Further study is required to determine ideal SBP goals after stroke. Clinical Trial Registration

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Association Between Blood Pressure Control and Risk of Recurrent Intracerebral Hemorrhage

Biffi

Anderson

Battey

et al. 2015

JAMA

210

243

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IMPORTANCE Intracerebral hemorrhage (ICH) is the most severe form of stroke. Survivors are at high risk of recurrence, death, and worsening functional disability. OBJECTIVE To investigate the association between blood pressure (BP) after index ICH and risk of recurrent ICH. DESIGN, SETTING, AND PARTICIPANTS Single-site, tertiary care referral center observational study of 1145 of 2197 consecutive patients with ICH presenting from July 1994 to December 2013. A total of 1145 patients with ICH survived at least 90 days and were followed up through December 2013 (median follow-up of 36.8 months [minimum, 9.8 months]). EXPOSURES Blood pressure measurements at 3, 6, 9, and 12 months, and every 6 months thereafter, obtained from medical personnel (inpatient hospital or outpatient clinic medical or nursing staff) or via patient self-report. Exposure was characterized in 3 ways: (1) recorded systolic and diastolic measurements; (2) classification as adequate or inadequate BP control based on American Heart Association/American Stroke Association recommendations; and (3) stage of hypertension based on Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 7 criteria. MAIN OUTCOMES AND MEASURES Recurrent ICH and its location within the brain (lobar vs nonlobar). RESULTS There were 102 recurrent ICH events among 505 survivors of lobar ICH and 44 recurrent ICH events among 640 survivors of nonlobar ICH. During follow-up adequate BP control was achieved on at least 1 measurement by 625 patients (54.6% of total [range, 49.2%-58.7%]) and consistently (ie, at all available time points) by 495 patients (43.2% of total [range, 34.5%-51.0%]). The event rate for lobar ICH was 84 per 1000 person-years among patients with inadequate BP control compared with 49 per 1000 person-years among patients with adequate BP control. For nonlobar ICH the event rate was 52 per 1000 person-years with inadequate BP control compared with 27 per 1000 person-years for patients with adequate BP control. In analyses modeling BP control as a time-varying variable, inadequate BP control was associated with higher risk of recurrence of both lobar ICH (hazard ratio [HR], 3.53 [95% CI, 1.65-7.54]) and nonlobar ICH (HR, 4.23 [95% CI, 1.02-17.52]). Systolic BP during follow-up was associated with increased risk of both lobar ICH recurrence (HR, 1.33 per 10-mm Hg increase [95% CI, 1.02-1.76]) and nonlobar ICH recurrence (HR, 1.54 [95% CI, 1.03-2.30]). Diastolic BP was associated with increased risk of nonlobar ICH recurrence (HR, 1.21 per 10-mm Hg increase [95% CI, 1.01-1.47]) but not with lobar ICH recurrence (HR, 1.36 [95% CI, 0.90-2.10]). CONCLUSIONS AND RELEVANCE In this observational single-center cohort study of ICH survivors, reported BP measurements suggesting inadequate BP control during follow-up were associated with higher risk of both lobar and nonlobar ICH recurrence. These data suggest that randomized clinical trials are needed to address the benefits and risks of stricter BP control in ICH ...

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Degree of blood pressure reduction and recurrent stroke: the PROGRESS trial

Abstract: The present analysis provided no evidence of an increase in recurrent stroke associated with larger reductions in SBP produced by treatment among patients with cerebrovascular disease.

Cited by 17 publications

References 5 publications

Blood pressure targets in type 2 diabetes. Evidence against or in favour of an aggressive approach

Blood pressure targets in type 2 diabetes. Evidence against or in favour of an aggressive approach

Systolic Blood Pressure Control and Mortality After Stroke in Hypertensive Patients

Association Between Blood Pressure Control and Risk of Recurrent Intracerebral Hemorrhage

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