Download PDF
Semin Neurol 2017; 37(03): 274-285
DOI: 10.1055/s-0037-1603501
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Blood Pressure and Prevention of Stroke

Katarina Dakay
1   Department of Neurology, UMass Memorial Medical Center, UMass Medical School, Worcester, Massachusetts
,
Brian Silver
1   Department of Neurology, UMass Memorial Medical Center, UMass Medical School, Worcester, Massachusetts
› Author Affiliations
Further Information

Publication History

Publication Date:
31 July 2017 (online)

    Permissions and Reprints

Abstract

Stroke is a common cause of morbidity and mortality worldwide, and hypertension is the most common modifiable risk factor for stroke. The treatment of hypertension reduces the primary occurrence of stroke as well as the risk of stroke recurrence. Although there are conflicting data regarding the optimal blood pressure for stroke prevention, an individualized approach taking into account the patient's age, comorbidities, and side effects of medication is a helpful strategy. Current guidelines support the pursuit of a systolic blood pressure under 140 mm Hg for both primary and secondary stroke prevention, though recent data suggest a more intensive goal may be of benefit in select patients. Certain classes of antihypertensives may be more beneficial in stroke prevention than others. Trials are underway to further study the optimal blood pressure target for stroke prevention in specific populations as well as the potential benefits of intensive blood pressure reduction beyond the current guidelines.

Keywords

hypertension - blood pressure - prevention - stroke
 

  • References

  • 1 Davis SM, Donnan GA. Clinical practice. Secondary prevention after ischemic stroke or transient ischemic attack. N Engl J Med 2012; 366 (20) 1914-1922
    CrossrefPubMedGoogle Scholar
  • 2 Roger VL, Go AS, Lloyd-Jones DM. , et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics--2011 update: a report from the American Heart Association. Circulation 2011; 123 (04) e18-e209
    CrossrefPubMedGoogle Scholar
  • 3 Feigin VL, Roth GA, Naghavi M. , et al; Global Burden of Diseases, Injuries and Risk Factors Study 2013 and Stroke Experts Writing Group. 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 2016; 15 (09) 913-924
    CrossrefPubMedGoogle Scholar
  • 4 Kecklund G, Axelsson J. Health consequences of shift work and insufficient sleep. BMJ 2016; 355: i5210
    CrossrefPubMedGoogle Scholar
  • 5 De Giusti M, Dito E, Pagliaro B. , et al. A survey on blood pressure levels and hypertension control in a sample of the Italian general population. High Blood Press Cardiovasc Prev 2012; 19 (03) 129-135
    PubMedGoogle Scholar
  • 6 Poggi L, Chamontin B, Lang T. , et al. An attempt to improve blood pressure control in the French population: information and outcome awareness at the general practitioner level. Am J Hypertens 1998; 11 (07) 905-908
    CrossrefPubMedGoogle Scholar
  • 7 Yoon SS, Gu Q, Nwankwo T, Wright JD, Hong Y, Burt V. Trends in blood pressure among adults with hypertension: United States, 2003 to 2012. Hypertension 2015; 65 (01) 54-61
    CrossrefPubMedGoogle Scholar
  • 8 Gu Q, Burt VL, Dillon CF, Yoon S. Trends in antihypertensive medication use and blood pressure control among United States adults with hypertension: the National Health And Nutrition Examination Survey, 2001 to 2010. Circulation 2012; 126 (17) 2105-2114
    CrossrefPubMedGoogle Scholar
  • 9 Siddiqui M, Calhoun DA. Refractory versus resistant hypertension. Curr Opin Nephrol Hypertens 2017; 26 (01) 14-19
    CrossrefPubMedGoogle Scholar
  • 10 Gioia LC, Zewude RT, Kate MP. , et al. Prehospital systolic blood pressure is higher in acute stroke compared with stroke mimics. Neurology 2016; 86 (23) 2146-2153
    CrossrefPubMedGoogle Scholar
  • 11 Mustanoja S, Putaala J, Gordin D. , et al. Acute-phase blood pressure levels correlate with a high risk of recurrent strokes in young-onset ischemic stroke. Stroke 2016; 47 (06) 1593-1598
    CrossrefPubMedGoogle Scholar
  • 12 Hemphill III JC, Greenberg SM, Anderson CS. , et al; American Heart Association Stroke Council; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2015; 46 (07) 2032-2060
    CrossrefPubMedGoogle Scholar
  • 13 Qureshi AI, Palesch YY, Barsan WG. , et al; ATACH-2 Trial Investigators and the Neurological Emergency Treatment Trials Network. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. N Engl J Med 2016; 375 (11) 1033-1043
    CrossrefPubMedGoogle Scholar
  • 14 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 (05) 1315-1320
    CrossrefPubMedGoogle Scholar
  • 15 Grise EM, Adeoye O. Blood pressure control for acute ischemic and hemorrhagic stroke. Curr Opin Crit Care 2012; 18 (02) 132-138
    CrossrefPubMedGoogle Scholar
  • 16 McManus M, Liebeskind DS. Blood pressure in acute ischemic stroke. J Clin Neurol 2016; 12 (02) 137-146
    CrossrefPubMedGoogle Scholar
  • 17 Jauch EC, Saver JL, Adams Jr HP. , et al; American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council on Clinical Cardiology. 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 (03) 870-947
    CrossrefPubMedGoogle Scholar
  • 18 Rusanen H, Saarinen JT, Sillanpää N. The association of blood pressure and collateral circulation in hyperacute ischemic stroke patients treated with intravenous thrombolysis. Cerebrovasc Dis 2015; 39 (02) 130-137
    CrossrefPubMedGoogle Scholar
  • 19 Martins AI, Sargento-Freitas J, Silva F. , et al. Recanalization modulates association between blood pressure and functional outcome in acute ischemic stroke. Stroke 2016; 47 (06) 1571-1576
    CrossrefPubMedGoogle Scholar
  • 20 Gill D, Cox T, Aravind A. , et al. A fall in systolic blood pressure 24 hours after thrombolysis for acute ischemic stroke is associated with early neurological recovery. J Stroke Cerebrovasc Dis 2016; 25 (06) 1539-1543
    CrossrefPubMedGoogle Scholar
  • 21 Schrader J, Lüders S, Kulschewski A. , et al; Acute Candesartan Cilexetil Therapy in Stroke Survivors Study Group. The ACCESS Study: evaluation of acute candesartan cilexetil therapy in stroke survivors. Stroke 2003; 34 (07) 1699-1703
    CrossrefPubMedGoogle Scholar
  • 22 He J, Zhang Y, Xu T. , et al; CATIS Investigators. 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 (05) 479-489
    CrossrefPubMedGoogle Scholar
  • 23 Ahmed N, Näsman P, Wahlgren NG. Effect of intravenous nimodipine on blood pressure and outcome after acute stroke. Stroke 2000; 31 (06) 1250-1255
    CrossrefPubMedGoogle Scholar
  • 24 Robinson TG, Potter JF, Ford GA. , et al; COSSACS Investigators. Effects of antihypertensive treatment after acute stroke in the Continue or Stop Post-Stroke Antihypertensives Collaborative Study (COSSACS): a prospective, randomised, open, blinded-endpoint trial. Lancet Neurol 2010; 9 (08) 767-775
    CrossrefPubMedGoogle Scholar
  • 25 Goldstein LB, Bushnell CD, Adams RJ. , et al; American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Epidemiology and Prevention; Council for High Blood Pressure Research; Council on Peripheral Vascular Disease, and Interdisciplinary Council on Quality of Care and Outcomes Research. Guidelines for the Primary Prevention of Stroke: a Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke 2011; 42 (02) 517-584
    CrossrefPubMedGoogle Scholar
  • 26 James PA, Oparil S, Carter BL. , 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 (05) 507-520
    CrossrefPubMedGoogle Scholar
  • 27 Prabhakaran S, Chong JY. Risk factor management for stroke prevention. Continuum (Minneap Minn) 2014; 20 (2 Cerebrovascular Disease): 296-308
    PubMedGoogle Scholar
  • 28 Materson BJ, Reda DJ, Cushman WC. , et al; The Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents. Single-drug therapy for hypertension in men. A comparison of six antihypertensive agents with placebo. N Engl J Med 1993; 328 (13) 914-921
    CrossrefPubMedGoogle Scholar
  • 29 Dahlöf B, Devereux RB, Kjeldsen SE. , et al; LIFE Study Group. Cardiovascular morbidity and mortality in the Losartan intervention for endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet 2002; 359 (9311): 995-1003
    CrossrefPubMedGoogle Scholar
  • 30 Lindholm LH, Ibsen H, Dahlöf B. , et al; LIFE Study Group. Cardiovascular morbidity and mortality in patients with diabetes in the Losartan intervention for endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet 2002; 359 (9311): 1004-1010
    CrossrefPubMedGoogle Scholar
  • 31 Rothwell PM, Howard SC, Dolan E. , et al; ASCOT-BPLA and MRC Trial Investigators. Effects of beta blockers and calcium-channel blockers on within-individual variability in blood pressure and risk of stroke. Lancet Neurol 2010; 9 (05) 469-480
    CrossrefPubMedGoogle Scholar
  • 32 Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G. ; 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 (03) 145-153
    CrossrefPubMedGoogle Scholar
  • 33 Carey RM, Siragy HM. Newly recognized components of the renin-angiotensin system: potential roles in cardiovascular and renal regulation. Endocr Rev 2003; 24 (03) 261-271
    CrossrefPubMedGoogle Scholar
  • 34 Hansson L, Lindholm LH, Niskanen L. , 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 (9153): 611-616
    CrossrefPubMedGoogle Scholar
  • 35 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
    CrossrefPubMedGoogle Scholar
  • 36 Ostergren J, Poulter NR, Sever PS. , et al; ASCOT investigators. The Anglo-Scandinavian Cardiac Outcomes Trial: blood pressure-lowering limb: effects in patients with type II diabetes. J Hypertens 2008; 26 (11) 2103-2111
    CrossrefPubMedGoogle Scholar
  • 37 Furberg CDWJ, Davis BR, Cutler JA. , et al; ALLHAT Collaborative Research Group. Major cardiovascular events in hypertensive patients randomized to doxazosin vs chlorthalidone: the antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT). JAMA 2000; 283 (15) 1967-1975
    CrossrefPubMedGoogle Scholar
  • 38 Furberg CDWJ, Davis BR, Cutler JA. , et al; 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 (23) 2981-2997
    CrossrefPubMedGoogle Scholar
  • 39 De Lima LG, Saconato H, Atallah AN, da Silva EM. Beta-blockers for preventing stroke recurrence. Cochrane Database Syst Rev 2014; (10) CD007890
    PubMedGoogle Scholar
  • 40 Beckett NS, Peters R, Fletcher AE. , et al; HYVET Study Group. Treatment of hypertension in patients 80 years of age or older. N Engl J Med 2008; 358 (18) 1887-1898
    CrossrefPubMedGoogle Scholar
  • 41 Perry Jr HM, Davis BR, Price TR. , et al. Effect of treating isolated systolic hypertension on the risk of developing various types and subtypes of stroke: the Systolic Hypertension in the Elderly Program (SHEP). JAMA 2000; 284 (04) 465-471
    CrossrefPubMedGoogle Scholar
  • 42 Staessen JA, Fagard R, Thijs L. , et al; The Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. Lancet 1997; 350 (9080): 757-764
    CrossrefPubMedGoogle Scholar
  • 43 Wright Jr JT, Whelton PK, Reboussin DM. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med 2016; 374 (23) 2294
    PubMedGoogle Scholar
  • 44 Silver B, Anderson CS. Review of the systolic blood pressure intervention trial for hypertension management: how low to go for patients with stroke?. Stroke 2016; 47 (06) 1692-1694
    CrossrefPubMedGoogle Scholar
  • 45 Kernan WN, Ovbiagele B, Black HR. , et al; American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Peripheral Vascular Disease. 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 (07) 2160-2236
    CrossrefPubMedGoogle Scholar
  • 46 Liu L, Wang Z, Gong L. , 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 (11) 1032-1040
    CrossrefPubMedGoogle Scholar
  • 47 Shimada K. Recurrent Stroke Prevention Clinical Outcome Study. Available at: https://clinicaltrialsgov/ct2/show/NCT01198496?term=NCT01198496&rank=1NLM . Identifier: NCT01198496. Accessed February 28, 2017
    PubMedGoogle Scholar
  • 48 Yusuf S, Diener HC, Sacco RL. , et al; PRoFESS Study Group. Telmisartan to prevent recurrent stroke and cardiovascular events. N Engl J Med 2008; 359 (12) 1225-1237
    CrossrefPubMedGoogle Scholar
  • 49 Anderson CTGI. Triple Therapy Prevention of Recurrent Intracerebral Disease EveNts Trial (TRIDENT). Available at: https://clinicaltrialsgov/ct2/show/NCT02699645?term=trident&rank=4 NLM Identifier: NCT02699645. Accessed February 28, 2017
    PubMedGoogle Scholar
  • 50 Schrader J, Lüders S, Kulschewski A. , et al; MOSES Study Group. Morbidity and mortality after stroke, eprosartan compared with nitrendipine for secondary prevention: principal results of a prospective randomized controlled study (MOSES). Stroke 2005; 36 (06) 1218-1226
    CrossrefPubMedGoogle Scholar
  • 51 Zhao M, Li X, Zheng L. , et al. Optimal blood pressure in patients after stroke in rural areas of China. J Stroke Cerebrovasc Dis 2016; 25 (02) 270-280
    CrossrefPubMedGoogle Scholar
  • 52 Ovbiagele B, Diener HC, Yusuf S. , et al; PROFESS Investigators. Level of systolic blood pressure within the normal range and risk of recurrent stroke. JAMA 2011; 306 (19) 2137-2144
    PubMedGoogle Scholar
  • 53 Kim J, Gall SL, Nelson MR, Sharman JE, Thrift AG. Lower systolic blood pressure is associated with poorer survival in long-term survivors of stroke. J Hypertens 2014; 32 (04) 904-911
    CrossrefPubMedGoogle Scholar
  • 54 Kaplan RC, Tirschwell DL, Longstreth Jr WT. , et al. Blood pressure level and outcomes in adults aged 65 and older with prior ischemic stroke. J Am Geriatr Soc 2006; 54 (09) 1309-1316
    CrossrefPubMedGoogle Scholar
  • 55 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 (01) 133-140
    CrossrefPubMedGoogle Scholar
  • 56 Turan TN, Nizam A, Lynn MJ. , et al. Relationship between risk factor control and vascular events in the SAMMPRIS trial. Neurology 2017; 88 (04) 379-385
    CrossrefPubMedGoogle Scholar
  • 57 Powers WJ, Clarke WR, Grubb Jr RL, Videen TO, Adams Jr HP, Derdeyn CP. ; COSS Investigators. Lower stroke risk with lower blood pressure in hemodynamic cerebral ischemia. Neurology 2014; 82 (12) 1027-1032
    CrossrefPubMedGoogle Scholar
  • 58 Towfighi A, Markovic D, Ovbiagele B. Consistency of blood pressure control after ischemic stroke: prevalence and prognosis. Stroke 2014; 45 (05) 1313-1317
    CrossrefPubMedGoogle Scholar
  • 59 Rothwell PM, Howard SC, Dolan E. , et al. Prognostic significance of visit-to-visit variability, maximum systolic blood pressure, and episodic hypertension. Lancet 2010; 375 (9718): 895-905
    CrossrefPubMedGoogle Scholar
  • 60 Manning LS, Rothwell PM, Potter JF, Robinson TG. Prognostic Significance of Short-Term Blood Pressure Variability in Acute Stroke: Systematic Review. Stroke 2015; 46 (09) 2482-2490
    CrossrefPubMedGoogle Scholar
  • 61 Drawz PE, Pajewski NM, Bates JT. , et al. Effect of intensive versus standard clinic-based hypertension management on ambulatory blood pressure: results from the sprint (systolic blood pressure intervention trial) ambulatory blood pressure study. Hypertension 2017; 69 (01) 42-50
    CrossrefPubMedGoogle Scholar
  • 62 Tadic M, Cuspidi C, Hering D. Hypertension and cognitive dysfunction in elderly: blood pressure management for this global burden. BMC Cardiovasc Disord 2016; 16 (01) 208
    CrossrefPubMedGoogle Scholar
  • 63 Pendlebury ST, Rothwell PM. Prevalence, incidence, and factors associated with pre-stroke and post-stroke dementia: a systematic review and meta-analysis. Lancet Neurol 2009; 8 (11) 1006-1018
    CrossrefPubMedGoogle Scholar
  • 64 Emdin CA, Rothwell PM, Salimi-Khorshidi G. , et al. Blood pressure and risk of vascular dementia: evidence from a primary care registry and a cohort study of transient ischemic attack and stroke. Stroke 2016; 47 (06) 1429-1435
    CrossrefPubMedGoogle Scholar
  • 65 Sierra C. Associations between ambulatory blood pressure parameters and cerebral white matter lesions. Int J Hypertens 2011; 2011: 478710
    PubMedGoogle Scholar
  • 66 Yamamoto Y, Nagakane Y, Tomii Y, Akiguchi I. High morning and bedtime home blood pressures strongly predict for post-stroke cognitive impairment. J Stroke Cerebrovasc Dis 2016; 25 (08) 1856-1863
    CrossrefPubMedGoogle Scholar
  • 67 Tzourio C, Anderson C, Chapman N. , et al; PROGRESS Collaborative Group. Effects of blood pressure lowering with perindopril and indapamide therapy on dementia and cognitive decline in patients with cerebrovascular disease. Arch Intern Med 2003; 163 (09) 1069-1075
    CrossrefPubMedGoogle Scholar
  • 68 Mossello E, Pieraccioli M, Nesti N. , et al. Effects of low blood pressure in cognitively impaired elderly patients treated with antihypertensive drugs. JAMA Intern Med 2015; 175 (04) 578-585
    CrossrefPubMedGoogle Scholar
  • 69 Verghese J, Lipton RB, Hall CB, Kuslansky G, Katz MJ. Low blood pressure and the risk of dementia in very old individuals. Neurology 2003; 61 (12) 1667-1672
    CrossrefPubMedGoogle Scholar
  • 70 Weidung B, Littbrand H, Nordström P, Carlberg B, Gustafson Y. The association between SBP and mortality risk differs with level of cognitive function in very old individuals. J Hypertens 2016; 34 (04) 745-752
    CrossrefPubMedGoogle Scholar
  • 71 Lefferts WK, Heffernan KS, Barreira TV. Association between pulsatile blood pressure and cognitive performance among older adults: Insight from the National Health and Nutrition Examination Survey 1999-2002. Int J Cardiol 2016; 223: 981-984
    CrossrefPubMedGoogle Scholar
  • 72 McGuinness B, Todd S, Passmore P, Bullock R. Blood pressure lowering in patients without prior cerebrovascular disease for prevention of cognitive impairment and dementia. Cochrane Database Syst Rev 2009; (04) CD004034
    PubMedGoogle Scholar
  • 73 Peters R, Beckett N, Fagard R. , et al. Increased pulse pressure linked to dementia: further results from the Hypertension in the Very Elderly Trial - HYVET. J Hypertens 2013; 31 (09) 1868-1875
    CrossrefPubMedGoogle Scholar
  • 74 Reboussin DM. Systolic Blood Pressure Intervention Trial: Memory and Cognition in Decreased Hypertension (SPRINT-MIND). Available at: https://wwwnianihgov/alzheimers/clinical-trials/systolic-blood-pressure-intervention-trial-memory-and-cognition-decreased . Accessed February 28, 2017
    PubMedGoogle Scholar
  • 75 Benetos A, Bulpitt CJ, Petrovic M. , et al. An Expert Opinion From the European Society of Hypertension-European Union Geriatric Medicine Society Working Group on the Management of Hypertension in Very Old, Frail Subjects. Hypertension 2016; 67 (05) 820-825
    CrossrefPubMedGoogle Scholar
  • 76 Zanchetti ALL. Optimal Blood Pressure and Cholesterol Targets for Preventing Recurrent Stroke in Hypertensives (ESH-CHL-SHOT). Available at: https://clinicaltrialsgov/ct2/show/NCT01563731?term=elderly+stroke+blood+pressure&rank=3 . Accessed February 28, 2017
    PubMedGoogle Scholar