Blood-pressure targets in patients with recent lacunar stroke: the SPS3 randomised trial

Abstract

Background: Lowering of blood pressure prevents stroke but optimum target levels to prevent recurrent stroke are unknown. We investigated the effects of different blood-pressure targets on the rate of recurrent stroke in patients with recent lacunar stroke.

Methods: In this randomised open-label trial, eligible patients lived in North America, Latin America, and Spain and had recent, MRI-defined symptomatic lacunar infarctions. Patients were recruited between March, 2003, and April, 2011, and randomly assigned, according to a two-by-two multifactorial design, to a systolic-blood-pressure target of 130-149 mm Hg or less than 130 mm Hg. The primary endpoint was reduction in all stroke (including ischaemic strokes and intracranial haemorrhages). Analysis was done by intention to treat. This study is registered with ClinicalTrials.gov, number NCT 00059306.

Findings: 3020 enrolled patients, 1519 in the higher-target group and 1501 in the lower-target group, were followed up for a mean of 3·7 (SD 2·0) years. Mean age was 63 (SD 11) years. After 1 year, mean systolic blood pressure was 138 mm Hg (95% CI 137-139) in the higher-target group and 127 mm Hg (95% CI 126-128) in the lower-target group. Non-significant rate reductions were seen for all stroke (hazard ratio 0·81, 95% CI 0·64-1·03, p=0·08), disabling or fatal stroke (0·81, 0·53-1·23, p=0·32), and the composite outcome of myocardial infarction or vascular death (0·84, 0·68-1·04, p=0·32) with the lower target. The rate of intracerebral haemorrhage was reduced significantly (0·37, 0·15-0·95, p=0·03). Treatment-related serious adverse events were infrequent.

Interpretation: Although the reduction in stroke was not significant, our results support that in patients with recent lacunar stroke, the use of a systolic-blood-pressure target of less than 130 mm Hg is likely to be beneficial.

Funding: National Institutes of Health-National Institute of Neurological Disorders and Stroke (NIH-NINDS).

Trial registration: ClinicalTrials.gov NCT00059306.

Copyright © 2013 Elsevier Ltd. All rights reserved.

Figures

Figure 1

Systolic blood pressure by treatment group.

Figure 2

Probability of patients experiencing a primary event by time after randomization. Primary events were all recurrent strokes, myocardial infarction, or vascular death. HR=hazard ratio.

Figure 3

Primary outcome assessed by demographic and clinical subgroups. HR=hazard ratio. SBP=systolic blood pressure.

Figure 4

Randomised trials of long-term blood-pressure lowering for secondary stroke prevention.