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Targeting blood pressure for stroke prevention: current evidence and unanswered questions

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Abstract

High blood pressure (BP) is the leading modifiable risk factor of stroke worldwide. Although randomized clinical trials have demonstrated the beneficial effect of BP reduction on stroke risk, there are still insufficiently explored issues concerning the optimal personalized management of BP in stroke patients in terms of thresholds to be achieved and drug classes to be prescribed. Few data are available about BP control in specific clinical contexts such as in older patients, in various stroke subtypes, or in association with co-morbidities such as diabetes. In addition, although drug trials based their conclusions on achieved mean BP values, recent findings indicate that aspects such as circadian variations of BP and BP variability should be taken into account as well. This article aims to highlight current knowledge about BP control in stroke prevention and to provide new perspectives to be addressed in future studies so as to guide clinicians in their day-to-day practice.

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References

  1. Forouzanfar MH, Liu P, Roth GA, Ng M, Biryukov S, Marczak L et al (2017) Global burden of hypertension and systolic blood pressure of at least 110 to 115 mmHg, 1990–2015. JAMA 317:165–182

    PubMed  Google Scholar 

  2. Marshall IJ, Wang Y, McKevitt C, Rudd AG, Wolfe CD (2013) Trends in risk factor prevalence and management before first stroke: data from the South London Stroke Register 1995–2011. Stroke 44:1809–1816

    PubMed  Google Scholar 

  3. Anderson CS, Carter KN, Hackett ML, Feigin V, Barber PA, Broad JB et al (2005) Trends in stroke incidence in Auckland, New Zealand, during 1981 to 2003. Stroke 36:2087–2093

    PubMed  Google Scholar 

  4. Rothwell PM, Coull AJ, Giles MF, Howard SC, Silver LE, Bull LM et al (2004) Change in stroke incidence, mortality, case-fatality, severity, and risk factors in Oxfordshire, UK from 1981 to 2004 (Oxford Vascular Study). Lancet 363:1925–1933

    CAS  PubMed  Google Scholar 

  5. Heuschmann PU, Di Carlo A, Béjot Y, Rastenyte D, Ryglewicz D, Sarti C et al (2009) Incidence of stroke in Europe at the beginning of the 21st century. Stroke 40:1557–1563

    PubMed  Google Scholar 

  6. Béjot Y, Daubail B, Giroud M (2016) Epidemiology of stroke and transient ischemic attacks: current knowledge and perspectives. Rev Neurol (Paris) 172:59–68

    Google Scholar 

  7. Béjot Y, Troisgros O, Gremeaux V, Lucas B, Jacquin A, Khoumri C et al (2012) Poststroke disposition and associated factors in a population-based study: the Dijon Stroke Registry. Stroke 43:2071–2077

    PubMed  Google Scholar 

  8. Lewington S, Clarke R, Qizilbash N, Peto R, Collins R, Prospective Studies Collaboration (2002) Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 360:1903–1913

    PubMed  Google Scholar 

  9. O’Donnell MJ, Chin SL, Rangarajan S, Xavier D, Liu L, Zhang H et al (2016) Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-control study. Lancet 388:761–775

    PubMed  Google Scholar 

  10. Feigin VL, Roth GA, Naghavi M, Parmar P, Krishnamurthi R, Chugh S et al (2016) Global burden of stroke and risk factors in 188 countries, during 1990–2013: a systematic analysis for the global burden of disease study 2013. Lancet Neurol 15:913–924

    PubMed  Google Scholar 

  11. Ettehad D, Emdin CA, Kiran A, Anderson SG, Callender T, Emberson J et al (2016) Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet 387:957–967

    PubMed  Google Scholar 

  12. PROGRESS collaborative group (2001) Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6105 individuals with previous stroke or transient ischaemic attack. Lancet 358:1033–1041

    Google Scholar 

  13. Yusuf S, Diener HC, Sacco RL, Cotton D, Ounpuu S, Lawton WA et al (2008) Telmisartan to prevent recurrent stroke and cardiovascular events. N Engl J Med 359:1225–1237

    CAS  PubMed  PubMed Central  Google Scholar 

  14. Benavente OR, Coffey CS, Conwit R, Hart RG, McClure LA, Pearce LA et al (2013) Blood-pressure targets in patients with recent lacunar stroke: the SPS3 randomised trial. Lancet 382:507–515

    CAS  PubMed  Google Scholar 

  15. The Dutch TIA Trial Study Group (1993) Trial of secondary prevention with atenolol after transient ischemic attack or nondisabling ischemic stroke. Stroke 24:543–548

    Google Scholar 

  16. PATS Collaborating Group (1995) Post-stroke antihypertensive treatment study. A preliminary result. Chin Med J 108:710–717

    Google Scholar 

  17. Eriksson S, Olofsson BO, Wester PO, for the TEST study group (1995) Atenolol in secondary prevention after stroke. Cerebrovasc Dis 5:21–25

    Google Scholar 

  18. Liu LS, Gong LS, Wang W, Blood Pressure Lowering to Prevent Recurrent Stroke Study Group (2005) Effects of blood pressure lowering treatment on stroke recurrence in patients with cerebrovascular diseases-a large-scale, randomized, placebo controlled trial. Zhonghua Xin Xue Guan Bing Za Zhi 33:613–617

    CAS  PubMed  Google Scholar 

  19. Chapman N, Huxley R, Anderson C, Bousser MG, Chalmers J, Colman S et al (2004) Effects of a perindopril-based blood pressure-lowering regimen on the risk of recurrent stroke according to stroke subtype and medical history: the PROGRESS Trial. Stroke 35:116–121

    CAS  PubMed  Google Scholar 

  20. Obviagele B, Diener HC, Yusuf S, Martin RH, Cotton D, Vinisko R et al (2011) Level of systolic blood pressure within the normal range and risk of recurrent stroke. JAMA 306:2137–2144

    Google Scholar 

  21. Odden MC, McClure LA, Sawaya BP, White CL, Peralta CA, Field TS et al (2016) Achieved blood pressure and outcomes in the secondary prevention of small subcortical strokes trial. Hypertension 67:63–69

    CAS  PubMed  Google Scholar 

  22. Katsanos AH, Filippatou A, Manios E, Deftereos S, Parissis J, Frogoudaki A et al (2017) Blood pressure reduction and secondary stroke prevention: a systematic review and metaregression analysis of randomized clinical trials. Hypertension 69:171–179

    CAS  PubMed  Google Scholar 

  23. Carter AB (1970) Hypotensive therapy in stroke survivors. Lancet 1:485–489

    CAS  PubMed  Google Scholar 

  24. Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G (2000) Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med 342:145–153

    CAS  PubMed  Google Scholar 

  25. Hypertension-Stroke Cooperative Study Group (1974) Effect of antihypertensive treatment on stroke recurrence. JAMA 229:409–418

    Google Scholar 

  26. Martí Massó JF, Lozano R (1990) Nicardipine in the prevention of cerebral infarction. Clin Ther 12:344–351

    PubMed  Google Scholar 

  27. Schrader J, Lüders S, Kulschewski A, Hammersen F, Plate K, Berger J et al (2005) Morbidity and mortality after stroke, eprosartan compared with nitrendipine for secondary prevention: principal results of a prospective randomized controlled study (MOSES). Stroke 36:1218–1226

    CAS  PubMed  Google Scholar 

  28. Mant J, McManus RJ, Roalfe A, Fletcher K, Taylor CJ, Martin U et al (2016) Different systolic blood pressure targets for people with history of stroke or transient ischaemic attack: PAST-BP (prevention after stroke-blood pressure) randomised controlled trial. BMJ 352:i708

    PubMed  PubMed Central  Google Scholar 

  29. Lithell H, Hansson L, Skoog I, Elmfeldt D, Hofman A, Olofsson B et al (2003) The study on cognition and prognosis in the elderly (SCOPE): principal results of a randomized double-blind intervention trial. J Hypertens 21:875–886

    CAS  PubMed  Google Scholar 

  30. Derdeyn CP, Chimowitz MI, Lynn MJ, Fiorella D, Turan TN, Janis LS et al (2014) Aggressive medical treatment with or without stenting in high-risk patients with intracranial artery stenosis (SAMMPRIS): the final results of a randomised trial. Lancet 383:333–341

    PubMed  Google Scholar 

  31. Turan TN, Nizam A, Lynn MJ, Egan BM, Le NA, Lopes-Virella MF et al (2017) Relationship between risk factor control and vascular events in the SAMMPRIS trial. Neurology 88:379–385

    PubMed  PubMed Central  Google Scholar 

  32. Giroud M, Delpont B, Daubail B, Blanc C, Durier J, Giroud M, Béjot Y (2017) Temporal trends in sex differences with regard to stroke incidence: the Dijon Stroke Registry (1987–2012). Stroke 48:846–849

    PubMed  Google Scholar 

  33. Béjot Y, Bailly H, Graber M, Garnier L, Laville A, Dubourget L et al (2019) Impact of the ageing population on the burden of stroke: the Dijon Stroke Registry. Neuroepidemiology 52:78–85

    PubMed  Google Scholar 

  34. White CL, Szychowski JM, Pergola PE, Field TS, Talbert R, Lau H et al (2015) Can blood pressure be lowered safely in older adults with lacunar stroke? The secondary prevention of small subcortical strokes study experience. J Am Geriatr Soc 63:722–729

    PubMed  PubMed Central  Google Scholar 

  35. Beckett NS, Peters R, Fletcher AE, Staessen JA, Liu L, Dumitrascu D et al (2008) Treatment of hypertension in patients 80 years of age or older. N Engl J Med 358:1887–1898

    CAS  PubMed  Google Scholar 

  36. Wright JT, Williamson JD, Whelton PK, Snyder JK, Sink KM et al (2015) A randomized trial of intensive versus standard blood-pressure control. N Engl J Med 373:2103–2116

    CAS  Google Scholar 

  37. Williamson JD, Supiano MA, Applegate WB, Berlowitz DR, Campbell RC, Chertow GM et al (2016) Intensive vs standard blood pressure control and cardiovascular disease outcomes in adults aged ≥ 75 years: a randomized clinical trial. JAMA 315:2673–2682

    CAS  PubMed  PubMed Central  Google Scholar 

  38. Cushman C, Evans GW, Byington RP, Goff DC Jr, Grimm RH Jr, Cutler JA et al (2010) Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med 362:1575–1585

    PubMed  Google Scholar 

  39. Margolis KL, O’Connor PJ, Morgan TM, Buse JB, Cohen RM, Cushman WC et al (2014) Outcomes of combined cardiovascular risk factor management strategies in type 2 diabetes: the ACCORD randomized trial. Diabetes Care 37:1721–1728

    CAS  PubMed  PubMed Central  Google Scholar 

  40. Bangalore Kumar S, Lobach I, Messerli FH (2011) Blood pressure targets in subjects with type 2 diabetes mellitus/impaired fasting glucose: observations from traditional and bayesian random-effects meta-analyses of randomized trials. Circulation 123:2799–2810

    CAS  PubMed  Google Scholar 

  41. Brunström M, Carlberg B (2016) Effect of antihypertensive treatment at different blood pressure levels in patients with diabetes mellitus: systematic review and meta-analyses. BMJ 352:i717

    PubMed  PubMed Central  Google Scholar 

  42. Rothwell PM (2010) Limitations of the usual blood-pressure hypothesis and importance of variability, instability, and episodic hypertension. Lancet 375:938–948

    PubMed  Google Scholar 

  43. Rothwell PM, Howard SC, Dolan E, O'Brien E, Dobson JE, Dahlöf B et al (2010) Prognostic significance of visit-to-visit variability, maximum systolic blood pressure, and episodic hypertension. Lancet 375:895–905

    PubMed  Google Scholar 

  44. Rothwell PM, Howard SC, Dolan E, O'Brien E, Dobson JE, Dahlöf B, Poulter NR et al (2010) Effects of beta blockers and calcium-channel blockers on within-individual variability in blood pressure and risk of stroke. Lancet Neurol 9:469–480

    CAS  PubMed  Google Scholar 

  45. Webb AJ, Fischer U, Mehta Z, Rothwell PM (2010) Effects of antihypertensive-drug class on interindividual variation in blood pressure and risk of stroke: a systematic review and meta-analysis. Lancet 375:906–915

    CAS  PubMed  Google Scholar 

  46. Melhum MH, Liestøl K, Kjeldsen SE, Julius S, Hua TA, Rothwell PM et al (2018) Blood pressure variability and risk of cardiovascular events and death in patients with hypertension and different baseline risks. Eur Heart J 39:2243–2251

    Google Scholar 

  47. Yano Y, Kario K (2012) Nocturnal blood pressure, morning blood pressure surge, and cerebrovascular events. Curr Hypertens Rep 14:219–227

    PubMed  Google Scholar 

  48. Kario K, Pickering TG, Matsuo T, Hoshide S, Schwartz JE, Shimada K (2001) Stroke prognosis and abnormal nocturnal blood pressure falls in older hypertensives. Hypertension 38:852–857

    CAS  PubMed  Google Scholar 

  49. Kario K, Pickering TG, Umeda Y, Hoshide S, Hoshide Y, Morinari M et al (2003) Morning surge in blood pressure as a predictor of silent and clinical cerebrovascular disease in elderly hypertensives: a prospective study. Circulation 107:1401–1406

    PubMed  Google Scholar 

  50. Hoshide S, Yano Y, Haimoto H, Yamagiwa K, Uchiba K, Nagasaka S et al (2010) Morning and evening home blood pressure and risks of incident stroke and coronary artery disease in the Japanese general practice population: the Japan Morning Surge-Home Blood Pressure Study. Hypertension 68:54–61

    Google Scholar 

  51. Kario K, Saito I, Kushiro T, Teramukai S, Ishikawa Y, Mori Y et al (2014) Home blood pressure and cardiovascular outcomes in patients during antihypertensive therapy: primary results of HONEST, a large-scale prospective, real-world observational study. Hypertension 64:989–996

    CAS  PubMed  Google Scholar 

  52. Björklund K, Lind L, Zethelius B, Andrén B, Lithell H (2003) Isolated ambulatory hypertension predicts cardiovascular morbidity in elderly men. Circulation 107:1297–1302

    PubMed  Google Scholar 

  53. Pierdomenico SD, Lapenna D, Bucci A, Di Tommaso R, Di Mascio R, Manente BM et al (2005) Cardiovascular outcome in treated hypertensive patients with responder, masked, false resistant, and true resistant hypertension. Am J Hypertens 18:1422–1428

    PubMed  Google Scholar 

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Authors and Affiliations

  1. Dijon Stroke Registry, E7460, Pathophysiology and Epidemiology of Cerebro-Cardiovascular Diseases (PEC2), University Hospital of Dijon, University of Burgundy, Dijon, France

    Yannick Béjot

  2. Department of Neurology, University Hospital of Dijon, Hôpital François Mitterrand, 14 rue Paul Gaffarel, BP 77908, 21079, Dijon cedex, France

    Yannick Béjot

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  1. Yannick Béjot
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Correspondence to Yannick Béjot.

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The author received honoraria for or consulting fees from AstraZeneca, BMS, Pfizer, Medtronic, MSD France, Amgen, and Boehringer-Ingelheim. None are related to this article.

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Béjot, Y. Targeting blood pressure for stroke prevention: current evidence and unanswered questions. J Neurol 268, 785–795 (2021). https://doi.org/10.1007/s00415-019-09443-5

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