Blood Pressure Reduction and Secondary Stroke Prevention

Abstract

Evidence from randomized controlled trials (RCTs) supports the use of antihypertensive agents in the secondary prevention of patients with ischemic stroke (IS) or transient ischemic attack (TIA).1,2 However, since heterogeneity is present for several outcomes among these trials, current recommendations do not specifically address the intensity of blood pressure (BP) lowering for secondary stroke prevention. 1,2This heterogeneity has been attributed to both a potential class effect of antihypertensive drugs used (related also to the reduction of BP variability) 3 and differences in the degree of BP reduction using standard and aggressive antihypertensive strategies. 4 Moreover, the majority of RCTs of secondary stroke prevention did not specifically evaluate the association between the extent of BP reduction and long-term outcomes in patients with stroke or TIA, leading to increasing uncertainty about the optimal BP levels that should be aimed and achieved during secondary stroke prevention. 5,6 In view of the former considerations, we conducted a systematic review and metaregression analysis on the association of BP reduction with recurrent stroke and cardiovascular events using available RCT data on secondary stroke prevention. Methods Trial Identification and Data AbstractionThis meta-analysis has adopted the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) for systematic reviews and meta-analyses.7 Eligible RCTs of all antihypertensive treatments used in the secondary prevention of IS/TIA Abstract-Current recommendations do not specifically address the optimal blood pressure (BP) reduction for secondary stroke prevention in patients with previous cerebrovascular events. We conducted a systematic review and metaregression analysis on the association of BP reduction with recurrent stroke and cardiovascular events using data from randomized controlled clinical trials of secondary stroke prevention. For all reported events during each eligible study period, we calculated the corresponding risk ratios to express the comparison of event occurrence risk between patients randomized to antihypertensive treatment and those randomized to placebo. The extent of BP reduction is linearly associated with the magnitude of risk reduction in recurrent cerebrovascular and cardiovascular events. Strict and aggressive BP control seems to be essential for effective secondary stroke prevention.

Aerobic exercise interventions reduce blood pressure in patients after stroke or transient ischaemic attack: a systematic review and meta-analysis

“…53 While exercise causes immediate elevations in heart rate, cardiac output and peripheral vasodilatation through nitric oxide release, 54 the long-lasting effects that may mediate blood pressure reduction include enhanced endothelial sensitivity to nitric oxide, a reduction in sympathetic tone and salt load, all ultimately reducing systemic vascular resistance. 55 Antihypertensive therapy reduces the risk of secondary stroke by 24% and myocardial infarction by 21% when compared with placebo. 56 A recent meta-analysis of 10 RCTs evaluating antihypertensive therapy after stroke showed that these effects occurred with reductions in SBP of 5.1 mm Hg and DBP of 2.5 mm Hg across a range of antihypertensive classes.…”

Atrial Fibrillation and Hypertension

“…40 In a recent meta-analysis of hypertensive patients, antihypertensive treatment reduced the risk of recurrent stroke by 27%, disabling or fatal stroke by 29%, and cardiovascular death by 15%. 41 When meta-regression was applied, SBP reduction was significantly related to the lower risk of recurrent stroke, myocardial infarction, all-cause, and cardiovascular death. 41 Although better-controlled BP reduces the stroke risk, a prolong history of prior uncontrolled hypertension may lead to severe cerebral vascular changes, which may increased the stroke risk in case of excessive BP reduction.…”

“…41 When meta-regression was applied, SBP reduction was significantly related to the lower risk of recurrent stroke, myocardial infarction, all-cause, and cardiovascular death. 41 Although better-controlled BP reduces the stroke risk, a prolong history of prior uncontrolled hypertension may lead to severe cerebral vascular changes, which may increased the stroke risk in case of excessive BP reduction. Of note, specific data in regard to patients with both hypertension and AF are lacking.…”

Nationwide Impact of the 2017 American College of Cardiology/American Heart Association Blood Pressure Guidelines on Stroke Survivors

“…Their results need to be contrasted with the findings from a recent meta‐analysis of 14 randomized controlled trials of secondary stroke prevention that demonstrated a linear and positive association between BP reduction and the risk of recurrent stroke and cardiovascular events. The authors suggested that a target of <130 mm Hg may be effective for secondary stroke prevention 5. Altogether, these studies were among the catalyzers that helped revise hypertension definition, pharmacological treatment recommendation, and BP targets in the 2017 ACC/AHA guidelines.…”

“…It is purported that greater blood pressure (BP) awareness and treatment has significantly contributed to the decline in stroke mortality in the United States over the past decades 2. Indeed, a meta‐analysis of 14 randomized controlled trials has shown a nearly 30% reduction in the risk of stroke recurrence with BP treatment 5. In the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) guidelines, hypertension was defined for systolic BP (SBP) ≥140 or diastolic BP (DBP) ≥90 mm Hg, and pharmacological treatment in stroke survivors was recommended for SBP ≥140 or DBP ≥90 mm Hg 6.…”