Hypertension treatment is usually intended to prevent cardiovascular disease. Numerous randomized clinical trials testify to the wisdom of treating hypertension with drug therapy to reduce a patient's probability of heart disease, stroke, and kidney disease. A patient who has already had a stroke and has survived has about a one in six chance of having another stroke in the next 5 years. 1
Many of us worry about treating hypertension in someone who has suffered a stroke, since we are concerned that if the blood pressure is reduced excessively, it may extend a completed stroke or produce symptoms of cerebral ischemia, rendering the patient cognitively or physically disabled. Also, low blood pressure may contribute to an accident or a fall. Several recent studies have addressed this difficult issue.
The Heart Outcomes Prevention Evaluation (HOPE) 2 trial showed that the use of the angiotensin‐converting enzyme (ACE) inhibitor ramipril, when added to other drugs, was effective in reducing stroke in high‐risk patients with cardiovascular disease. The recent Perindopril Protection Against Recurrent Stroke Study (PROGRESS) 3 used the ACE inhibitor perindopril to treat patients with a history of a transient ischemic attack or stroke. This large trial involved more than 6000 patients. The results showed that perindopril (4 mg/day, with or without the diuretic indapamide at 2.0–2.5 mg/day) reduced the occurrence of stroke by 28% (95% confidence interval, 17%–38%). The combined treatment (perindopril and indapamide together) lowered blood pressure to a greater extent, and had a significantly more protective effect, than perindopril alone. The trial enrolled hypertensive and normotensive patients and the results applied equally to both groups. All types of stroke (except subarachnoid hemorrhage, an excluded condition) were reduced.
The level to which blood pressure should be lowered after stroke recovery is still not known. In the meantime, a reasonable strategy would be to lower blood pressure to as close to normal as possible (a systolic value of <140 mm Hg) in the post‐acute stroke period (>2 months afterward), using a combination regimen of a diuretic and an ACE inhibitor. Blood pressure should be lowered gradually, to reduce side effects and allow adaptation of cerebral blood flow through autoregulation. The results of future trials will hopefully clarify to what degree systolic blood pressure should be lowered.
References
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