Blood pressure and LDL-cholesterol targets for prevention of recurrent strokes and cognitive decline in the hypertensive patient

Zanchetti, Alberto; Liu, Lisheng; Mancia, Giuseppe; Parati, Gianfranco; Grassı, Guıdo; Stramba-Badiale, Marco; Silani, Vincenzo; Bilo, Grzegorz; Corrao, Giovanni; Zambon, Antonella; Scotti, Lorenza; Zhang, Xinhua; Wang, HayYan; Zhang, Yuqing; Zhang, Xuezhong; Guan, Ting; Berge, Eivind; Redón, Josep; Narkiewicz, Krzysztof; Dominiczak, Anna F.; Nilsson, Peter M.; Viigimaa, Margus; Laurent, Stéphane; Agabiti‐Rosei, Enrico; Wu, Zhaozhen; Zhu, Dingliang; Rodicio, José L.; Ruilope, Luís M.; Martell-Clarós, Nieves; Pinto, Fernando; Schmieder, Roland E.; Burnier, Michel; Banach, Maciej; Cífková, Renata; Farsang, Csaba; Конради, А. О.; Lazareva, I.; Sirenko, Yuriy; Dorobanțu, Maria; Postadzhiyan, Arman; Accetto, Rok; Jelaković, Bojan; Lović, Dragan; Manolis, Athanasios; Stylianou, Philippos; Erdine, Serap; Dicker, Dror; Wei, Guang Hui; Xu, Chang; Xie, Hui; Coca, António; O’Brien, John T.; Ford, Gary A.

doi:10.1097/hjh.0000000000000254

Cited by 65 publications

(30 citation statements)

References 14 publications

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“…However, the “nadir” SBP values may possibly vary in hypertensive patients with different ethnic backgrounds or concomitant baseline diseases. We agree that the controversy of “the lower the better” versus the J curve can only be solved by a series of well‐designed randomized trials, such as the ongoing Stroke in Hypertension Optimal Treatment (SHOT) study 25. Nevertheless, our current findings emphasize that patients with grade 1 hypertension should possibly avoid excessive SBP reduction during treatment.…”

Section: Discussionsupporting

confidence: 58%

Impact of Achieved Blood Pressure on First Stroke in Uncomplicated Grade 1 Hypertension

Sun

et al. 2017

JAHA

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BackgroundWe aimed to test the impact of achieved blood pressure (BP) on first stroke among patients with grade 1 hypertension and without cardiovascular diseases in the China Stroke Primary Prevention Trial.Methods and ResultsA total of 3187 patients with uncomplicated grade 1 hypertension were included. The risk of outcomes was assessed according to: (1) the proportion of visits in which BP was reduced to <140/90 mm Hg, and (2) the time‐averaged systolic BP (SBP) or diastolic BP levels during the study treatment period. The median antihypertensive treatment duration was 4.6 years. Only 1.5% of the participants discontinued the treatments because of adverse reaction. Overall, the risk of stroke decreased with the increase of the proportion of study visits with BP <140/90 mm Hg (for per 5% increase; hazard ratio, 0.92 [95% CI, 0.87–0.98]). Consistently, compared with patients with time‐averaged SBP ≥140 or diastolic BP ≥90 mm Hg, the risk of stroke was lower in patients with time‐averaged SBP of 120 to <140 mm Hg (1.1% versus 2.9%; hazard ratio, 0.39 [95% CI, 0.22–0.69]) or diastolic BP <90 mm Hg (1.5% versus 2.7%; hazard ratio, 0.41 [95% CI, 0.17–0.98]). The beneficial results were consistent across age (<60 versus ≥60 years), sex, baseline SBP (<150 versus 150 to <160 mm Hg), study treatment groups (enalapril or enalapril‐folic acid), and hypertension subtypes (isolated systolic hypertension or systolic‐diastolic hypertension). However, a time‐averaged SBP <120 mm Hg (versus 120–140 mm Hg) was associated with an increased risk for stroke. Similar results were observed for composite cardiovascular events or all‐cause death.ConclusionsAchieved BP <140/90 mm Hg was significantly associated with a decreased risk of stroke or all‐cause death in patients with uncomplicated grade 1 hypertension.

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Section: Discussionsupporting

confidence: 58%

Impact of Achieved Blood Pressure on First Stroke in Uncomplicated Grade 1 Hypertension

Sun

et al. 2017

JAHA

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“…Investigators are able to prescribe a statin of their choosing and cognition is assessed using the Montreal Cognitive Assessment (MoCA) as a secondary outcome over 4 years of follow-up [193].…”

Section: On-going and Future Research Possibilitiesmentioning

confidence: 99%

Hypercholesterolaemia and vascular dementia

et al. 2017

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Correspondence: Philip Bath (Philip.bath@nottingham.ac.uk) Vascular dementia (VaD) is the second commonest cause of dementia. Stroke is the leading cause of disability in adults in developed countries, the second major cause of dementia and the third commonest cause of death. Traditional vascular risk factors -diabetes, hypercholesterolaemia, hypertension and smoking -are implicated as risk factors for VaD. The associations between cholesterol and small vessel disease (SVD), stroke, cognitive impairment and subsequent dementia are complex and as yet not fully understood. Similarly, the effects of lipids and lipid-lowering therapy on preventing or treating dementia remain unclear; the few trials that have assessed lipid-lowering therapy for preventing (two trials) or treating (four trials) dementia found no evidence to support the use of lipid-lowering therapy for these indications. It is appropriate to treat those patients with vascular risk factors that meet criteria for lipid-lowering therapy for the primary and secondary prevention of cardiovascular and cerebrovascular events, and in line with current guidelines. Managing the individual patient in a holistic manner according to his or her own vascular risk profile is recommended. Although the paucity of randomized controlled evidence makes for challenging clinical decision making, it provides multiple opportunities for on-going and future research, as discussed here.

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“…16 However, there has been a relative paucity of data on the relationship of lower achieved SBP after stroke to mortality. [16][17][18] A recent analysis of long-term survivors of stroke 18 found that, compared with a reference SBP of 131 to 141 mm Hg, low SBP (≤120 mm Hg) measured 5 years after stroke was associated with an increased risk of all-cause mortality and the composite end point of recurrent stroke, myocardial infarction, or death over the ensuing 5 years. In contrast, neither patients with slightly lower SBP (121-130 mm Hg) or higher SBP (142-210 mm Hg) were at increased risk of dying or the composite end point.…”

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confidence: 99%

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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Blood pressure and LDL-cholesterol targets for prevention of recurrent strokes and cognitive decline in the hypertensive patient

Abstract: It has been calculated that 925 patients would reach the primary outcome after a mean 4-year follow-up, and this should provide at least 80% power to detect a 25% stroke difference between SBP targets and a 20% difference between LDL-C targets.

Cited by 65 publications

References 14 publications

Impact of Achieved Blood Pressure on First Stroke in Uncomplicated Grade 1 Hypertension

Impact of Achieved Blood Pressure on First Stroke in Uncomplicated Grade 1 Hypertension

Hypercholesterolaemia and vascular dementia

Systolic Blood Pressure Control and Mortality After Stroke in Hypertensive Patients

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