Editor—A strong evidence base exists for many aspects of stroke care particularly secondary prevention. Stroke units reduce death and disability regardless of severity, but only half of UK patients receive this care. The risk of stroke is greatest within the first few days after a transient ischaemic attack, yet waiting times for neurovascular clinics may be weeks or months even if a local service is available.
Hypertension is the most important risk factor for the primary prevention of stroke but before the perindopril protection against recurrent stroke study (PROGRESS) was published in 2001, uncertainty prevailed about the benefits of blood pressure lowering for secondary prevention.1 Since then the debate has changed to whether the substantial reduction in stroke risk seen in this trial (relative risk reduction 43%, 95% confidence interval 30 to 54) is due to specific effects of the combination of perinodopril and indapamide, indapamide alone, a class effect of these drugs, or blood pressure lowering itself.
These views are strongly held, as can be seen in the article by Wennberg and Zimmermann and the commentary by MacMahon et al.2 Surely the time has come to move on and look at the bigger picture, which is ensuring that blood pressure lowering and other effective measures are widely and appropriately implemented—for example, aspirin, cholesterol lowering, carotid endarterectomy for carotid stenosis, and warfarin for atrial fibrillation. Cost effective implementation strategies are required, not endless academic debate. Some will use perindopril and indapamide; others will use other blood pressure lowering drugs—three years on we need to agree to disagree and move on.
This important issue is that only 65% of hypertensive patients receive treatment at follow up after discharge.3 Surely patients deserve better?
Competing interests: HR was a site investigator for PROGRESS and has received lecture fees from Servier. She is a member of the Intercollegiate Stroke Working Party.
References
- 1.PROGRESS Collaborative Group. Randomised trial of perinopril-based blood pressure lowering regimen among 6105 individuals with previous stroke or transient ischaemic attack. Lancet 2001;358: 1033-41. [DOI] [PubMed] [Google Scholar]
- 2.Wennberg R, Zimmerman C. The PROGRESS trial three years later: time for a balanced report of effectiveness [with commentary by S MacMahon, B Neal, A Rodgers, J Chalmers]. BMJ 2004;329: 968-71. (23 October.) [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Intercollegiate Working Party for Stroke. Concise report on the national sentinel audit for stroke, 2001-2002. London: Royal College of Physicians, 2001.