The following Consensus Statement was adopted by the 4th Karolinska Stroke Update meeting on November 11, 2002.

The consensus statement was proposed by the chairpersons in the session, Professor Jan Lodder, Maastricht, , and Professor Bo Norrving, Lund, together with the speakers in the session. The statement was then finally approved by the participants of the meeting, after listening to the different presentations.

The speakers in this session were Associate Professor Andreas Terent, Uppsala, Associate Professor Jan Östergren, Stockholm, and Professor Rory Collins, Oxford.

What recommendation could be given for blood pressure lowering after stroke or TIA?

1. There are now studies which clearly show that lowering of blood pressure is effective, not only in primary prevention, but also in secondary prevention after stroke and TIA.

2. The PROGRESS trial demonstrated that against a background of standard treatment blood pressure reduction, a flexible regime with an ACE inhibitor (perindopril) and a diuretic (indapamide) was beneficial and reduced the risk of stroke by 28 % over 4 years. The regimen was safe and well-tolerated: after initial screening for tolerance during a four-week period only 1 % more patients stopped active therapy than those stopping placebo because of hypotension.

3. The target level of blood pressure control has not been precisely defined by PROGRESS, though benefit was present even in patients with baseline pressures less than 140/85. It appears that the lower the pressure, the lower the risk of stroke, but blood pressure lowering must take account adverse effects in individual patients. The only direct evidence of blood pressure lowering after stroke and TIA is for diuretic (indapamide) and ACE-inhibitor (perindopril). However, it may be that other blood pressure lowering agents are as effective and equally, or better tolerated.

4. In clinical practice, blood pressure lowering should now be considered in all patients after stroke and TIA. It appears reasonable to start blood pressure lowering with a thiazide or thiazide-like diuretic when the patient’s condition has stabilized, usually 2 weeks after stroke. An ACE-inhibitor should be added later, if necessary and appropriate. E g if the blood pressure was already persistently less than 130/70 most physicians would not attempt to lower it further.

5. Now that blood pressure lowering is likely to become more aggressive, it is extremely important to be alert to drug induced adverse effects and to react appropriately e g by reducing the dose or changing to a different drug.

What recommendation could be given for statins after stroke or TIA?

1. As yet specific data on the secondary preventive effect of statins in patients with stroke or TIA are available only from the stroke subgroup of a large randomised placebo-controlled study (Heart Protection Study, HPS) on high-risk patients. The result in this subgroup is similar to the overall result of the trial: about one quarter reduction in a combined end-point of serious vascular events (including stroke) and revascularization. The benefits were additional to existing treatments, and there were no substantial safety concerns. Although the dose of simvastatin of 40 mg was used in this trial the optimal dose of statins in secondary stroke prevention has not been established. Further data on the effect of statins in patients from an on-going large trial specifically in patients with stroke and TIA (SPARCLE) are expected to appear in 2004.

2. In clinical practice, secondary prevention with statins should now be considered in patients with stroke and TIA. Therapy with simvastatin 40 mg can be started already in the acute phase.