Blood Pressure Management for Stroke Prevention and in Acute Stroke

Keun-Sik Hong, Keun-Sik Hong

Abstract

Elevated blood pressure (BP) is the leading modifiable risk factor for stroke and the benefit of BP lowering therapy on the stroke risk reduction is well established. The optimal BP target for preventing stroke and other vascular events have been controversial, but the evidences from epidemiological studies and randomized controlled trials (RCTs) support intensive BP lowering for greater vascular protection, particularly for stroke prevention. For secondary stroke prevention, the evidence of intensive BP lowering benefit is limited since only a single RCT for patients with lacunar infarctions was conducted and most data were driven by exploratory analyses. In acute intracerebral hemorrhage, immediate BP lowering targeting systolic BP<140 mm Hg is recommended by guidelines based on the results from RCTs. In contrast, in acute ischemic stroke, early BP lowering is not usually recommended because of no benefit on functional outcome and future vascular events and potential harm of stroke progression. This review aims to summarize the updated evidence for optimal BP management for primary and secondary stroke prevention and in patients with acute stroke.

Keywords: Blood pressure; Intracerebral hemorrhage; Prevention, Acute ischemic stroke; Stroke.

Conflict of interest statement

The author has no financial conflicts of interest.

References

    1. WHO . A global brief on hypertension. Geneva: World Health Organization; 2013.
    1. O’Donnell MJ, Chin SL, Rangarajan S, Xavier D, Liu L, Zhang H, et al. Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-control study. Lancet. 2016;388:761–775.
    1. Lewington S, Clarke R, Qizilbash N, Peto R, Collins R; Prospective Studies Collaboration. 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. 2002;360:1903–1913.
    1. Lawes CM, Rodgers A, Bennett DA, Parag V, Suh I, Ueshima H, et al. Blood pressure and cardiovascular disease in the Asia Pacific region. J Hypertens. 2003;21:707–716.
    1. MacMahon S, Peto R, Cutler J, Collins R, Sorlie P, Neaton J, et al. Blood pressure, stroke, and coronary heart disease. Part 1, prolonged differences in blood pressure: prospective observational studies corrected for the regression dilution bias. Lancet. 1990;335:765–774.
    1. Rothwell PM, Coull AJ, Giles MF, Howard SC, Silver LE, Bull LM, et al. Change in stroke incidence, mortality, case-fatality, severity, and risk factors in Oxfordshire, UK from 1981 to 2004 (Oxford Vascular Study) Lancet. 2004;363:1925–1933.
    1. Carandang R, Seshadri S, Beiser A, Kelly-Hayes M, Kase CS, Kannel WB, et al. Trends in incidence, lifetime risk, severity, and 30-day mortality of stroke over the past 50 years. JAMA. 2006;296:2939–2946.
    1. Lackland DT, Roccella EJ, Deutsch AF, Fornage M, George MG, Howard G, et al. Factors influencing the decline in stroke mortality: a statement from the American Heart Association/American Stroke Association. Stroke. 2014;45:315–353.
    1. Kubo M, Kiyohara Y, Kato I, Tanizaki Y, Arima H, Tanaka K, et al. Trends in the incidence, mortality, and survival rate of cardiovascular disease in a Japanese community: the Hisayama study. Stroke. 2003;34:2349–2354.
    1. James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8) JAMA. 2014;311:507–520.
    1. Dong C, Della-Morte D, Rundek T, Wright CB, Elkind MS, Sacco RL. Evidence to maintain the systolic blood pressure treatment threshold at 140 mm Hg for stroke prevention: the Northern Manhattan Study. Hypertension. 2016;67:520–526.
    1. Psaty BM, Lumley T, Furberg CD, Schellenbaum G, Pahor M, Alderman MH, et al. Health outcomes associated with various antihypertensive therapies used as first-line agents: a network meta-analysis. JAMA. 2003;289:2534–2544.
    1. Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ. 2009;338:b1665.
    1. Ettehad D, Emdin CA, Kiran A, Anderson SG, Callender T, Emberson J, et al. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet. 2016;387:957–967.
    1. Hansson L, Lindholm LH, Ekbom T, Dahlöf B, Lanke J, Scherstén B, et al. Randomised trial of old and new antihypertensive drugs in elderly patients: cardiovascular mortality and morbidity the Swedish trial in old patients with hypertension-2 study. Lancet. 1999;354:1751–1756.
    1. Hansson L, Lindholm LH, Niskanen L, Lanke J, Hedner T, Niklason A, et al. Effect of angiotensin-converting-enzyme inhibition compared with conventional therapy on cardiovascular morbidity and mortality in hypertension: the captopril prevention project (CAPPP) randomised trial. Lancet. 1999;353:611–616.
    1. Brown MJ, Palmer CR, Castaigne A, de Leeuw PW, Mancia G, Rosenthal T, et al. Morbidity and mortality in patients randomised to double-blind treatment with a long-acting calcium-channel blocker or diuretic in the International Nifedipine GITS study: intervention as a goal in hypertension treatment (INSIGHT) Lancet. 2000;356:366–372.
    1. Hansson L, Hedner T, Lund-Johansen P, Kjeldsen SE, Lindholm LH, Syvertsen JO, et al. Randomised trial of effects of calcium antagonists compared with diuretics and beta-blockers on cardiovascular morbidity and mortality in hypertension: the Nordic Diltiazem (NORDIL) study. Lancet. 2000;356:359–365.
    1. Dahlöf B, Devereux RB, Kjeldsen SE, Julius S, Beevers G, de Faire U, 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.
    1. Dahlöf B, Sever PS, Poulter NR, Wedel H, Beevers DG, Caulfield M, et al. Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the anglo-scandinavian cardiac outcomes trial-blood pressure lowering arm (ASCOT-BPLA): a multicentre randomised controlled trial. Lancet. 2005;366:895–906.
    1. Major cardiovascular events in hypertensive patients randomized to doxazosin vs chlorthalidone: the antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT). ALLHAT Collaborative Research Group. JAMA. 2000;283:1967–1975.
    1. ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: the antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT) JAMA. 2002;288:2981–2997.
    1. Jamerson K, Weber MA, Bakris GL, Dahlöf B, Pitt B, Shi V, et al. Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients. N Engl J Med. 2008;359:2417–2428.
    1. Matsuzaki M, Ogihara T, Umemoto S, Rakugi H, Matsuoka H, Shimada K, et al. Prevention of cardiovascular events with calcium channel blocker-based combination therapies in patients with hypertension: a randomized controlled trial. J Hypertens. 2011;29:1649–1659.
    1. Grau AJ, Weimar C, Buggle F, Heinrich A, Goertler M, Neumaier S, et al. Risk factors, outcome, and treatment in subtypes of ischemic stroke: the German stroke data bank. Stroke. 2001;32:2559–2566.
    1. Kimura K, Kazui S, Minematsu K, Yamaguchi T, Japan Multicenter Stroke Investigator’s Collaboration Analysis of 16,922 patients with acute ischemic stroke and transient ischemic attack in Japan. A hospital-based prospective registration study. Cerebrovasc Dis. 2004;18:47–56.
    1. Fonarow GC, Reeves MJ, Smith EE, Saver JL, Zhao X, Olson DW, et al. Characteristics, performance measures, and inhospital outcomes of the first one million stroke and transient ischemic attack admissions in get with the guidelines-stroke. Circ Cardiovasc Qual Outcomes. 2010;3:291–302.
    1. Kim BJ, Park JM, Kang K, Lee SJ, Ko Y, Kim JG, et al. Case characteristics, hyperacute treatment, and outcome information from the clinical research center for stroke-fifth division registry in South Korea. J Stroke. 2015;17:38–53.
    1. Carter AB. Hypotensive therapy in stroke survivors. Lancet. 1970;1:485–489.
    1. Effect of antihypertensive treatment on stroke recurrence. Hypertension-Stroke Cooperative Study Group. JAMA. 1974;229:409–418.
    1. Trial of secondary prevention with atenolol after transient ischemic attack or nondisabling ischemic stroke. The Dutch TIA Trial Study Group. Stroke. 1993;24:543–548.
    1. Eriksson S, Olofsson BO, Wester PO. Atenolol in secondary prevention after stroke. Cerebrovasc Dis. 1995;5:21–25.
    1. PATS Collaborating Group Post-stroke antihypertensive treatment study. A preliminary result. Chin Med J (Engl) 1995;108:710–717.
    1. Liu L, Wang Z, Gong L, Zhang Y, Thijs L, Staessen JA, et al. Blood pressure reduction for the secondary prevention of stroke: a Chinese trial and a systematic review of the literature. Hypertens Res. 2009;32:1032–1040.
    1. PROGRESS Collaborative Group Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6,105 individuals with previous stroke or transient ischaemic attack. Lancet. 2001;358:1033–1041.
    1. Rashid P, Leonardi-Bee J, Bath P. Blood pressure reduction and secondary prevention of stroke and other vascular events: a systematic review. Stroke. 2003;34:2741–2748.
    1. Yusuf S, Diener HC, Sacco RL, Cotton D, Ounpuu S, Lawton WA, et al. Telmisartan to prevent recurrent stroke and cardiovascular events. N Engl J Med. 2008;359:1225–1237.
    1. Katsanos AH, Filippatou A, Manios E, Deftereos S, Parissis J, Frogoudaki A, et al. Blood pressure reduction and secondary stroke prevention: a systematic review and metaregression analysis of randomized clinical trials. Hypertension. 2017;69:171–179.
    1. Towfighi A, Markovic D, Ovbiagele B. Consistency of blood pressure control after ischemic stroke: prevalence and prognosis. Stroke. 2014;45:1313–1317.
    1. Ovbiagele B, Diener HC, Yusuf S, Martin RH, Cotton D, Vinisko R, et al. Level of systolic blood pressure within the normal range and risk of recurrent stroke. JAMA. 2011;306:2137–2144.
    1. Rothwell PM, Howard SC, Spence JD, Carotid Endarterectomy Trialists’ Collaboration Relationship between blood pressure and stroke risk in patients with symptomatic carotid occlusive disease. Stroke. 2003;34:2583–2590.
    1. Chaturvedi S, Turan TN, Lynn MJ, Kasner SE, Romano J, Cotsonis G, et al. Risk factor status and vascular events in patients with symptomatic intracranial stenosis. Neurology. 2007;69:2063–2068.
    1. Turan TN, Lynn MJ, Nizam A, Lane B, Egan BM, Le NA, et al. Rationale, design, and implementation of aggressive risk factor management in the stenting and aggressive medical management for prevention of recurrent stroke in intracranial stenosis (SAMMPRIS) trial. Circ Cardiovasc Qual Outcomes. 2012;5:e51–e60.
    1. Turan TN, Nizam A, Lynn MJ, Egan BM, Le NA, Lopes-Virella MF, et al. Relationship between risk factor control and vascular events in the SAMMPRIS trial. Neurology. 2017;88:379–385.
    1. Waters MF, Hoh BL, Lynn MJ, Kwon HM, Turan TN, Derdeyn CP, et al. Factors associated with recurrent ischemic stroke in the medical group of the SAMMPRIS Trial. JAMA Neurol. 2016;73:308–315.
    1. Messerli FH, Mancia G, Conti CR, Hewkin AC, Kupfer S, Champion A, et al. Dogma disputed: can aggressively lowering blood pressure in hypertensive patients with coronary artery disease be dangerous? Ann Intern Med. 2006;144:884–893.
    1. Sleight P, Redon J, Verdecchia P, Mancia G, Gao P, Fagard R, et al. Prognostic value of blood pressure in patients with high vascular risk in the ongoing telmisartan alone and in combination with ramipril global endpoint trial study. J Hypertens. 2009;27:1360–1369.
    1. ACCORD Study Group. Cushman WC, Evans GW, Byington RP, Goff DC, Jr, Grimm RH, Jr, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010;362:1575–1585.
    1. Bangalore S, Kumar S, Lobach I, Messerli FH. 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. 2011;123:2799–2810. 9 p following 2810.
    1. Fan F, Yuan Z, Qin X, Li J, Zhang Y, Li Y, et al. Optimal systolic blood pressure levels for primary prevention of stroke in general hypertensive adults: findings from the CSPPT (China stroke primary prevention trial) Hypertension. 2017;69:697–704.
    1. Lee M, Saver JL, Hong KS, Hao Q, Ovbiagele B. Does achieving an intensive versus usual blood pressure level prevent stroke? Ann Neurol. 2012;71:133–140.
    1. Xie X, Atkins E, Lv J, Bennett A, Neal B, Ninomiya T, et al. Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis. Lancet. 2016;387:435–443.
    1. SPRINT Research Group. Wright JT, Jr, Williamson JD, Whelton PK, Snyder JK, Sink KM, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373:2103–2116.
    1. Perkovic V, Rodgers A. Redefining blood-pressure targets--SPRINT starts the marathon. N Engl J Med. 2015;373:2175–2178.
    1. Lonn EM, Bosch J, López-Jaramillo P, Zhu J, Liu L, Pais P, et al. Blood-pressure lowering in intermediate-risk persons without cardiovascular disease. N Engl J Med. 2016;374:2009–2020.
    1. Arima H, Chalmers J, Woodward M, Anderson C, Rodgers A, Davis S, et al. Lower target blood pressures are safe and effective for the prevention of recurrent stroke: the PROGRESS trial. J Hypertens. 2006;24:1201–1208.
    1. Turan TN, Cotsonis G, Lynn MJ, Chaturvedi S, Chimowitz M, Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) Trial Investigators Relationship between blood pressure and stroke recurrence in patients with intracranial arterial stenosis. Circulation. 2007;115:2969–2975.
    1. Powers WJ, Clarke WR, Grubb RL, Jr, Videen TO, Adams HP, Jr, Derdeyn CP, et al. Lower stroke risk with lower blood pressure in hemodynamic cerebral ischemia. Neurology. 2014;82:1027–1032.
    1. Amin-Hanjani S, Turan TN, Du X, Pandey DK, Rose-Finnell L, Richardson D, et al. Higher stroke risk with lower blood pressure in hemodynamic vertebrobasilar disease: analysis from the VERiTAS study. J Stroke Cerebrovasc Dis. 2017;26:403–410.
    1. SPS3 Study Group. Benavente OR, Coffey CS, Conwit R, Hart RG, McClure LA, et al. Blood-pressure targets in patients with recent lacunar stroke: the SPS3 randomised trial. Lancet. 2013;382:507–515.
    1. Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45:2160–2236.
    1. Qureshi AI, Ezzeddine MA, Nasar A, Suri MF, Kirmani JF, Hussein HM, et al. Prevalence of elevated blood pressure in 563,704 adult patients with stroke presenting to the ED in the United States. Am J Emerg Med. 2007;25:32–38.
    1. Leonardi-Bee J, Bath PM, Phillips SJ, Sandercock PA, IST Collaborative Group Blood pressure and clinical outcomes in the international stroke trial. Stroke. 2002;33:1315–1320.
    1. Schrader J, Lüders S, Kulschewski A, Berger J, Zidek W, Treib J, et al. The ACCESS study: evaluation of acute candesartan cilexetil therapy in stroke survivors. Stroke. 2003;34:1699–1703.
    1. Potter JF, Robinson TG, Ford GA, Mistri A, James M, Chernova J, et al. Controlling hypertension and hypotension immediately post-stroke (CHHIPS): a randomised, placebo-controlled, double-blind pilot trial. Lancet Neurol. 2009;8:48–56.
    1. Sandset EC, Bath PM, Boysen G, Jatuzis D, Kõrv J, Lüders S, et al. The angiotensin-receptor blocker candesartan for treatment of acute stroke (SCAST): a randomised, placebo-controlled, double-blind trial. Lancet. 2011;377:741–750.
    1. Oh MS, Yu KH, Hong KS, Kang DW, Park JM, Bae HJ, et al. Modest blood pressure reduction with valsartan in acute ischemic stroke: a prospective, randomized, open-label, blinded-end-point trial. Int J Stroke. 2015;10:745–751.
    1. Jusufovic M, Sandset EC, Bath PM, Karlson BW, Berge E; Scandinavian Candesartan Acute Stroke Trial Study Group. Effects of blood pressure lowering in patients with acute ischemic stroke and carotid artery stenosis. Int J Stroke. 2015;10:354–359.
    1. He J, Zhang Y, Xu T, Zhao Q, Wang D, Chen CS, et al. Effects of immediate blood pressure reduction on death and major disability in patients with acute ischemic stroke: the CATIS randomized clinical trial. JAMA. 2014;311:479–489.
    1. Lee M, Ovbiagele B, Hong KS, Wu YL, Lee JE, Rao NM, et al. Effect of blood pressure lowering in early ischemic stroke: meta-analysis. Stroke. 2015;46:1883–1889.
    1. Jauch EC, Saver JL, Adams HP, Jr, Bruno A, Connors JJ, Demaerschalk BM, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44:870–947.
    1. TIMI Study Group Comparison of invasive and conservative strategies after treatment with intravenous tissue plasminogen activator in acute myocardial infarction. Results of the thrombolysis in myocardial infarction (TIMI) phase II trial. N Engl J Med. 1989;320:618–627.
    1. GUSTO investigators An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N Engl J Med. 1993;329:673–682.
    1. Wahlgren N, Ahmed N, Eriksson N, Aichner F, Bluhmki E, Dávalos A, et al. Multivariable analysis of outcome predictors and adjustment of main outcome results to baseline data profile in randomized controlled trials: safe Implementation of thrombolysis in stroke-monitoring study (SITS-MOST) Stroke. 2008;39:3316–3322.
    1. Ahmed N, Wahlgren N, Brainin M, Castillo J, Ford GA, Kaste M, et al. Relationship of blood pressure, antihypertensive therapy, and outcome in ischemic stroke treated with intravenous thrombolysis: retrospective analysis from safe implementation of thrombolysis in stroke-international stroke thrombolysis register (SITS-ISTR) Stroke. 2009;40:2442–2449.
    1. Huang Y, Sharma VK, Robinson T, Lindley RI, Chen X, Kim JS, et al. Rationale, design, and progress of the enhanced control of hypertension and thrombolysis stroke study (ENCHANTED) trial: an international multicenter 2 x 2 quasi-factorial randomized controlled trial of low- vs. standard-dose rt-PA and early intensive vs. guideline-recommended blood pressure lowering in patients with acute ischaemic stroke eligible for thrombolysis treatment. Int J Stroke. 2015;10:778–788.
    1. Martins AI, Sargento-Freitas J, Silva F, Jesus-Ribeiro J, Correia I, Gomes JP, et al. Recanalization modulates association between blood pressure and functional outcome in acute ischemic stroke. Stroke. 2016;47:1571–1576.
    1. Hemphill JC, 3rd, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46:2032–2060.
    1. Steiner T, Al-Shahi Salman R, Beer R, Christensen H, Cordonnier C, Csiba L, et al. European stroke organisation (ESO) guidelines for the management of spontaneous intracerebral hemorrhage. Int J Stroke. 2014;9:840–855.
    1. Anderson CS, Huang Y, Wang JG, Arima H, Neal B, Peng B, et al. Intensive blood pressure reduction in acute cerebral haemorrhage trial (INTERACT): a randomised pilot trial. Lancet Neurol. 2008;7:391–399.
    1. Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) investigators Antihypertensive treatment of acute cerebral hemorrhage. Crit Care Med. 2010;38:637–648.
    1. Anderson CS, Heeley E, Huang Y, Wang J, Stapf C, Delcourt C, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013;368:2355–2365.
    1. Qureshi AI, Palesch YY, Barsan WG, Hanley DF, Hsu CY, Martin RL, et al. Intensive blood-pressure lowering in patients with acute cerebral hemorrhage. N Engl J Med. 2016;375:1033–1043.

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