Blood pressure-lowering treatment for preventing recurrent stroke, major vascular events, and dementia in patients with a history of stroke or transient ischaemic attack

Zonneveld, Thomas P.; Richard, Edo; Vergouwen, Mervyn D.I.; Nederkoorn, Paul J.; Haan, Rob J. de; Roos, Yvo B.W.E.M.; Kruyt, Nyika D.

doi:10.1002/14651858.cd007858.pub2

Cited by 83 publications

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“…7 In primary prevention, the Systolic Blood Pressure Intervention Trial (SPRINT) 11 proved the benefit of aggressive BP control, demonstrating that targeting a systolic BP less than 120 mm Hg resulted in lower rates of major cardiovascular events compared with less than 140 mm Hg. Although a pooled analysis of 3 studies [12][13][14] (3632 participants) comparing different systolic BP targets suggested that intensive BP lowering reduced the rate of recurrent stroke, no clinical trials to date have tested the effect of such aggressive BP lowering for secondary stroke prevention. In the Recurrent Stroke Prevention Clinical Outcome (RESPECT) Study, we herein tested the hypothesis that targeting intensive BP lowering of systolic and diastolic blood BP less than 120 mm Hg and less than 80 mm Hg, respectively, reduces the rate of stroke recurrence compared with a standard BP-lowering regimen.…”

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Effect of Standard vs Intensive Blood Pressure Control on the Risk of Recurrent Stroke

et al. 2019

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; for the Recurrent Stroke Prevention Clinical Outcome (RESPECT) Study Group IMPORTANCE The Systolic Blood Pressure Intervention Trial (SPRINT) demonstrated that a systolic blood pressure (BP) target less than 120 mm Hg was superior to less than 140 mm Hg for preventing vascular events. This trial excluded patients with prior stroke; therefore, the ideal BP target for secondary stroke prevention remains unknown. OBJECTIVE To assess whether intensive BP control would achieve fewer recurrent strokes vs standard BP control. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial (RCT) of standard vs intensive BP control in an intent-to-treat population of patients who had a history of stroke. Patients were enrolled between October 20, 2010, and December 7, 2016. For an updated meta-analysis, PubMed and the Cochrane Central Library database were searched through September 30, 2018, using the Medical Subject Headings and relevant search terms for cerebrovascular disease and for intensive BP lowering. This was a multicenter trial that included 140 hospitals in Japan; 1514 patients who had a history of stroke within the previous 3 years were approached, but 234 refused to give informed consent. INTERVENTIONS In total, 1280 patients were randomized 1:1 to BP control to less than 140/90 mm Hg (standard treatment) (n = 640) or to less than 120/80 mm Hg (intensive treatment) (n = 640). However, 17 patients never received intervention; therefore, 1263 patients assigned to standard treatment (n = 630) or intensive treatment (n = 633) were analyzed. MAIN OUTCOMES AND MEASURES The primary outcome was stroke recurrence. RESULTS The trial was stopped early. Among 1263 analyzed patients (mean [SD] age, 67.2 [8.8] years; 69.4% male), 1257 of 1263 (99.5%) completed a mean (SD) of 3.9 (1.5) years of follow-up. The mean BP at baseline was 145.4/83.6 mm Hg. Throughout the overall follow-up period, the mean BP was 133.2/77.7 (95% CI, 132.5-133.8/77.1-78.4) mm Hg in the standard group and 126.7/77.4 (95% CI, 125.9-127.2/73.8-75.0) mm Hg in the intensive group. Ninety-one first recurrent strokes occurred. Nonsignificant rate reductions were seen for recurrent stroke in the intensive group compared with the standard group (hazard ratio [HR], 0.73; 95% CI, 0.49-1.11; P = .15). When this finding was pooled in 3 previous relevant RCTs in a meta-analysis, the risk ratio favored intensive BP control (relative risk, 0.78; 95% CI, 0.64-0.96; P = .02; absolute risk difference, −1.5%; 95% CI, −2.6% to −0.4%; number needed to treat, 67; 95% CI, 39-250). CONCLUSIONS AND RELEVANCE Intensive BP lowering tended to reduce stroke recurrence. The updated meta-analysis supports a target BP less than 130/80 mm Hg in secondary stroke prevention.

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Effect of Standard vs Intensive Blood Pressure Control on the Risk of Recurrent Stroke

et al. 2019

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“…Prevention of stroke recurrence following initial stroke or transient ischaemic attack (TIA) is an important focus for secondary prevention, the risk being substantially reduced by good blood pressure (BP) control [1][2][3]. Usual care following stroke and TIA therefore includes regular BP checks and monitoring of anti-hypertensive medications, which are usually carried out in primary care.…”

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Self-Monitoring and Management of Blood Pressure in Patients with Stroke or TIA: An Economic Evaluation of TEST-BP, A Randomised Controlled Trial

Kim

Wilson

Davison

et al. 2020

PharmacoEconomics Open

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Background Prevention of secondary stroke following initial ictus is an important focus of after-stroke care. Blood pressure (BP) is a key risk factor, so usual care following stroke or transient ischaemic attack includes regular BP checks and monitoring of anti-hypertensive medication. This is traditionally carried out in primary care, but the evidence supporting self-monitoring and self-guided management of BP in the general population with hypertension is growing. Objective Our objective was to estimate the cost effectiveness of treatment as usual (TAU) versus (1) self-monitoring of BP (S-MON) and (2) self-monitoring and guided self-management of anti-hypertensive medication (S-MAN). Methods This was a within-trial economic evaluation of a randomised controlled trial estimating the incremental cost per 1 mmHg BP reduction and per quality-adjusted life-year (QALY) gained over a 6-month time horizon from the perspective of the UK National Health Service (NHS). Results Data were evaluable for 140 participants. Costs per patient were £473, £853 and £1035; mean reduction in systolic BP (SBP) was 3.6, 6.7 and 6.1 mmHg, and QALYs accrued were 0.427, 0.422 and 0.423 for TAU, S-MON and S-MAN, respectively. No statistically significant differences in incremental costs or outcomes were detected. On average, S-MAN was dominated or extended dominated. The incremental cost per 1 mmHg BP reduction from S-MON versus TAU was £137. Conclusion On average, S-MAN is an inefficient intervention. S-MON may be cost effective, depending on the willingness to pay for a 1 mmHg BP reduction, although it yielded fewer QALYs over the within-trial time horizon. Decision modelling is required to explore the longer-term costs and outcomes.

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“…В 2018 г. в Кокрановской базе данных T. Zonneveld и соавт. [11] опубликовали крупный обзор по проблеме снижения АД для предотвращения рецидивов инсульта, крупных сосудистых событий и деменции у пациентов с инсультом или ТИА в анамнезе. Целью данного обзора стало изучение эффективности антигипертензивных препаратов, прием которых начат по меньшей мере через 48 ч после постановки диагноза инсульта, для профилактики повторного инсульта, больших ССС и деменции у пациентов с инсультом или ТИА в анамнезе.…”

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“…Авторы этого крупного Кокрановского обзора [11] на основании полученных данных сделали заключение, что полученные результаты не позволяют сделать выводы относительно оптимального целевого уровня САД у пациентов с перенесенным инсультом или ТИА в анамнезе.…”

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Evidence base regarding target levels of arterial pressure in patients after a stroke: focus on a geriatric population

et al. 2020

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Arterial hypertension (AH) is a very significant and most common risk factor for stroke, and lowering blood pressure (BP) is the most effective action to prevent stroke in patients with AH. This article provides an overview of existing randomized clinical trials (RCTs) and meta-analyzes to study the optimal target BP levels in patients with AH and cerebral events with a history of focusing on the geriatric population. As a result of the analysis of literature data, we obtained contradictory results: RCTs showed the benefits of lower target BP, in only two of them the target level of systolic BP (SBP) was less than 130 mm Hg, and the average age of patients included in the RCTs varied from 60 to 68 years, the number of patients older than 75 years was insignificant, and some studies excluded patients older than 85 years. Several subanalyses analyzed by RCTs found a J-shaped relationship between BP levels achieved and the risk of adverse cardiovascular events. One of them showed that with a decrease in BP below the SBP 120 mm Hg and DBP 65 mm Hg higher BP was associated with a lower risk of cardiovascular events. Another one showed that the risk of re-stroke and the risk of subsequent adverse events was statistically significantly higher in patients with an average level of SBP below 120 mm Hg than in patients with a level of SBP of 130139 mm Hg. The meta-analysis published in the Cochrane database did not show significant advantages of lowering BP130/85 mm Hg versus standard lowering BP140160/90100 mm Hg, while another meta-analysis revealed some advantages of a more intense decrease in BP for the prevention of re-stroke. Existing studies did not take into account the heterogeneity of the geriatric population and did not include patients with fraility and multimorbidity patients, and did not take into account the type of stroke to develop a differentiated approach to the tactics of lowering BP in patients of all age groups. Therefore, in relation to the recommended ESC/ESH experts in 2018, target BP levels of 120129/7079 mm Hg (aged 1865 years) and 130139/7079 mmHg (aged 65 years) for patients with AH and a history of cerebral events, there are still some doubts about the benefits of lower target BP values for the prevention of re-stroke and other cardiovascular events for the entire population of geriatric patients, especially patients older than 75, so specially designed randomized controlled trials are needed.

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Blood pressure-lowering treatment for preventing recurrent stroke, major vascular events, and dementia in patients with a history of stroke or transient ischaemic attack

Abstract: Blood pressure-lowering treatment for preventing recurrent stroke, major vascular events, and dementia in patients with a history of stroke or transient ischaemic attack.

Cited by 83 publications

References 56 publications

Effect of Standard vs Intensive Blood Pressure Control on the Risk of Recurrent Stroke

Effect of Standard vs Intensive Blood Pressure Control on the Risk of Recurrent Stroke

Self-Monitoring and Management of Blood Pressure in Patients with Stroke or TIA: An Economic Evaluation of TEST-BP, A Randomised Controlled Trial

Evidence base regarding target levels of arterial pressure in patients after a stroke: focus on a geriatric population

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