Current Treatment Options in Neurology

, Volume 8, Issue 6, pp 486–495

Update on the management of hypertension to prevent stroke

  • Laura Pedelty
  • Philip B. Gorelick
Article
  • 39 Downloads

Opinion statement

Hypertension is the leading modifiable risk factor for stroke, including first-ever and recurrent stroke. The association between blood pressure (BP) and stroke risk is continuous and may be documented as low as 115/75 mm Hg. Because of this continuum of risk, and because most strokes occur in individuals with mild hypertension or even normal BP values, we are now beginning to recognize “prehypertension” as a stage in which early recognition and intervention may confer benefit. In addition to increased risk for ischemic and hemorrhagic stroke, hypertension may be associated with increased risk of cognitive impairment. Reductions in BP are reliably associated with reduced stroke risk. Some evidence suggests that certain agents, including angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, may have protective effects beyond BP lowering. Overall, the degree of BP lowering is key, and therefore most classes of BP-lowering agents may be recommended at this point. Many patients with hypertension will require more than one BP-lowering agent to control BP. Lifestyle modification is appropriate at all levels of intervention. Further studies are needed to ascertain the mechanisms of benefit of different classes of antihypertensive agents in the reduction of stroke and cardiovascular disease risk.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References and Recommended Reading

  1. 1.
    American Heart Association: Heart Disease and Stroke Statistics--2005 Update. Dallas, TX: American Heart Association; 2005.Google Scholar
  2. 2.
    Lawes CMM, Bennett DA, Feigin VL, Rodgers A: Blood pressure and stroke. An overview of published reviews. Stroke 2004, 35:1024–1033.PubMedCrossRefGoogle Scholar
  3. 3.
    Neal B, McMahon S, Chapman N, Blood Pressure Lowering Treatment Trialists’ Collaboration: Effects of ACE inhibitors, calcium antagonists, and other bloodpressure-lowering drugs: results of prospectively designed overviews of randomized trials. Lancet 2000, 356:1955–1964.PubMedCrossRefGoogle Scholar
  4. 4.
    Chobanian A, Bakris G, Black H, et al.: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The JNC 7 Report. JAMA 2003, 289:2560–2572. The “bible” for blood pressure management guidelines in the United States.PubMedCrossRefGoogle Scholar
  5. 5.
    Kearney P, Whelton M, Reynolds K, et al.: Global burden of hypertension: analysis of worldwide data. Lancet Neurol 2005, 365:217–223.Google Scholar
  6. 6.
    Gorelick P: Stroke prevention therapy beyond antithrombotics: unifying mechanisms in ischemic stroke pathogenesis and implications for therapy. An invited review. Stroke 2002, 33:862–875.PubMedCrossRefGoogle Scholar
  7. 7.
    Gorelick P: New horizons for stroke prevention: PROGRESS and HOPE. Lancet Neurol 2002, 1:149–156.PubMedCrossRefGoogle Scholar
  8. 8.
    McMahon S, Neal B, Rodgers A: Hypertension--time to move on. Lancet 2005, 365:1108–1109.Google Scholar
  9. 9.
    Giles T, Berk B, Black H, et al.: Expanding the definition and classification of hypertension. J Clin Hypertens 2005, 7:505–512. A new look at classifying and defining hypertension.CrossRefGoogle Scholar
  10. 10.
    Julius S, Nesbitt S, Egan B, et al.: Feasibility of treating prehypertension with an angiotensin-receptor blocker. N Engl J Med 2006, 354:1685–1697.PubMedCrossRefGoogle Scholar
  11. 11.
    Williams B, Lacy P, Thom S, et al.: Differential impact of blood pressure-lowering drugs on central aortic pressure and clinical outcomes. Principal results of the Conduit Artery Function Evaluation (CAFÉ). Circulation 2006, 113:1213–1225.PubMedCrossRefGoogle Scholar
  12. 12.
    Brewster L, van Monthrans G, Kleijnen J: Systematic review: antihypertensive drug therapy in blacks. Ann Intern Med 2004, 141:614–627.PubMedGoogle Scholar
  13. 13.
    Goldstein L, Adams R, Alberts M, et al.: Primary prevention of ischemic stroke. A guideline from the American Heart Association/American Stroke Association Stroke Council. Stroke 2006, 37:1583–1633.PubMedGoogle Scholar
  14. 14.
    Pedelty L, Gorelick P: Chronic management of blood pressure after stroke. Hypertension 2004, 44:1–5. A concise reference that answers five key questions frequently asked by practitioners in relation to chronic blood pressure management after stroke.PubMedCrossRefGoogle Scholar
  15. 15.
    Sacco R, Adams R, Albers G, et al.: Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke. Stroke 2006, 37:577–617.PubMedCrossRefGoogle Scholar
  16. 16.
    PROGRESS Collaborative Study Group: Randomized trial of a perindopril-based blood-pressure-lowering regimen among 6105 individuals with previous stroke or transient ischemic attack. Lancet 2001, 358:1033–1041.CrossRefGoogle Scholar
  17. 17.
    Schrader J, Luders S, Kulschewski A, et al.: Morbidity and mortality after stroke, eprosartan compared with nitrendipine for secondary stroke prevention. Principal results of a prospective randomized controlled study (MOSES). Stroke 2005, 36:1218–1226.PubMedCrossRefGoogle Scholar
  18. 18.
    Hanley D, Gorelick P, Elliott W, et al.: Determining the appropriateness of selected surgical and medical management options in recurrent stroke prevention: a guideline for primary care physicians from the National Stroke Association Work Group on Recurrent Stroke Prevention. J Stroke Cerebrovasc Dis 2004, 13:196–207.CrossRefGoogle Scholar
  19. 19.
    Gorelick P: Prevention. In Vascular Cognitive Impairment: Preventable Dementia. Edited by Bowler J, Hachinski V. New York: Oxford University Press; 2003:308–320.Google Scholar
  20. 20.
    Feigin V, Ratnasabapathy Y, Anderson C: Does blood pressure lowering treatment prevent dementia or cognitive decline in patients with cardiovascular and cerebrovascular disease? J Neurol Sci 2005, 229–230:151–155. A thoughtful systematic analysis of blood pressure lowering treatment and prevention of dementia or cognitive decline. More data are needed to answer the important question relating to blood pressure lowering or treatment and preservation of cognitive vitality.PubMedCrossRefGoogle Scholar
  21. 21.
    Dufouil C, Chalmers J, Coksun O, et al.: Effects of blood pressure lowering on cerebral white matter hypertensities in patients with stroke. The PROGRESS (Perindopril Protection Against Recurrent Stroke) Study. Magnetic Resonance Imaging Substudy. Circulation 2005, 112:1644–1650.PubMedCrossRefGoogle Scholar
  22. 22.
    McGuinness B, Todd S, Passmore P, Bullock R: The effects of blood pressure lowering on development of cognitive impairment and dementia in patients without apparent prior cerebrovascular disease. Cochrane Database Syst Rev 2006, 2.Google Scholar
  23. 23.
    Gorelick P, William M: Feinberg Lecture: cognitive vitality and the role of stroke and cardiovascular disease risk factors. Stroke 2005, 36:875–879. A concise summary of stroke and cardiovascular risk factors and their role in conferring risk of AD and VCI.PubMedCrossRefGoogle Scholar
  24. 24.
    Sacks F, Svetky L, Vollmer W, et al.: Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. N Engl J Med 2001, 344:3–10.PubMedCrossRefGoogle Scholar
  25. 25.
    Xin X, He J, Frontini M, et al.: Effects of alcohol reduction on blood pressure: a meta-analysis of randomized controlled trials. Hypertension 2001, 38:1112–1117.PubMedGoogle Scholar
  26. 26.
    Whelton S, Chin A, Xin X, He J: Effect of aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials. Ann Intern Med 2002, 136:493–503.PubMedGoogle Scholar
  27. 27.
    The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group: Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic. JAMA 2002, 288:2981–2997.CrossRefGoogle Scholar
  28. 28.
    Psaty B, Smith N, Siscovick D: Health outcomes associated with antihypertensive therapies used as first-line agents: a systematic review and meta-analysis. JAMA 1997, 277:739–745.PubMedCrossRefGoogle Scholar
  29. 29.
    The Heart Outcomes Prevention Evaluation Study Investigators: Effects of an angiotensin-converting enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. N Engl J Med 2000, 342:145–153.CrossRefGoogle Scholar
  30. 30.
    Dahlof B, Devereaux R, Kjeldsen S, et al.: Cardiovascular morbidity and mortality in the Losartan Intervention for Endpoint Reduction in Hypertension study (LIFE): a randomised trial against atenolol. Lancet 2002, 359:995–1003.PubMedCrossRefGoogle Scholar
  31. 31.
    Angeli F, Verdecchia P, Reboldi G, et al.: Calcium channel blockers to prevent stroke in hypertension: a metaanalysis of 13 studies with 103,793 subjects. Am J Hypertens 2004, 17:817–822.PubMedGoogle Scholar
  32. 32.
    Hunt S, Abraham W, Chin M, et al.: ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation 2005, 112:e154-e235.PubMedCrossRefGoogle Scholar
  33. 33.
    American Diabetes Association: Treatment of hypertension in adults with diabetes. Diabetes Care 2003, 26:S80-S82.CrossRefGoogle Scholar
  34. 34.
    National Kidney Foundation Guidelines. K/DOQI clinical practice guidelines for chronic kidney disease: Kidney Disease Outcome Quality Initiative. Am J Kidney Dis 2002, 39:S1–266.CrossRefGoogle Scholar
  35. 35.
    Pedelty L, Gorelick P: Stroke risk factors: impact and management. In The Stroke Book. Edited by Torbey M, Selim M. Cambridge: Cambridge University Press; In press.Google Scholar

Copyright information

© Current Science Inc 2006

Authors and Affiliations

  • Laura Pedelty
    • 1
  • Philip B. Gorelick
  1. 1.Department of Neurology and RehabilitationUniversity of Illinois College of Medicine at ChicagoChicagoUSA

Personalised recommendations