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The Perindopril Protection Against Recurrent Stroke Study (PROGRESS)

Clinical Implications for Older Patients with Cerebrovascular Disease

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Abstract

Blood pressure levels are strongly predictive of the risks of first-ever and recurrent stroke. The benefits of blood pressure-lowering therapy for the prevention of fatal and non-fatal stroke in middle-aged individuals are well established. However, until recently, there has been uncertainty about the consistency of such benefits across different patient groups and in particular, for older people and in those with a history of stroke. This paper discusses the evidence surrounding the effectiveness of blood pressure-lowering therapy, specifically in older patients with a history of stroke, with particular attention paid to the results from the Perindopril Protection Against Recurrent Stroke Study (PROGRESS).

PROGRESS was a randomised, double-blind, placebo-controlled trial of 6105 individuals with a history of cerebrovascular disease recruited from 172 hospital outpatient clinics in ten countries. Participants (mean age 64 years; range 26–91 years) were randomly assigned to receive active treatment with an ACE inhibitor-based blood pressure-lowering regimen (perindopril) with or without addition of the diuretic indapamide, or matched placebo. At the end of follow up (mean of 4 years), active treatment reduced the incidence of total stroke by 28% (95% CI 17–38%) and the rate of major vascular events by 26% (95% CI 16–34%). Importantly, benefits of treatment were consistent across key patient subgroups, including those with and without hypertension, patients who were Asian and non-Asian, and for both ischaemic and haemorrhagic strokes subtypes.

Current evidence is now strong for clinicians to consider blood pressure-lowering therapy as pivotal in the prevention of stroke, especially in patients with a known history of cerebrovascular disease (and vascular disease, in general), irrespective of blood pressure levels, as soon as patients are clinically stable after an acute stroke or other vascular event. Additional age-specific analyses of the PROGRESS data, together with those from other completed trials, will provide more reliable information about the size of the benefits of blood pressure-lowering therapy, specifically for different age groups, and particularly in the oldest old (those aged >80 years). In the meantime though, an ACE inhibitor plus diuretic treatment regimen that maximises the degree of blood pressure reduction has a good safety profile and is an effective treatment that should be considered in all patients with stroke, including the elderly.

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Acknowledgements

Professor Anderson is a member of the PROGRESS Management Committee and Dr Ratnasabapathy was a Research Fellow associated with the PROGRESS study. Dr Lawes is supported by a Research Training Fellowship of the Health Research Council of New Zealand and is associated with the Asia Pacific Cohort Studies Collaboration. No external funds were used in the preparation of this manuscript.

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  1. Clinical Trials Research Unit, Department of Medicine, The University of Auckland, Private Bag 92019, Auckland, New Zealand

    Yogini Ratnasabapathy, Carlene M. M. Lawes &  Craig S. Anderson

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  1. Yogini Ratnasabapathy
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  3. Craig S. Anderson
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Correspondence to Craig S. Anderson.

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Ratnasabapathy, Y., Lawes, C.M.M. & Anderson, C.S. The Perindopril Protection Against Recurrent Stroke Study (PROGRESS). Drugs Aging 20, 241–251 (2003). https://doi.org/10.2165/00002512-200320040-00001

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