Blood pressure control and secondary stroke prevention - Karolinska Stroke Update
Consensus Statement 2004
|The following Consensus Statement was adopted by the 5th Karolinska Stroke Update meeting on
November 15, 2004.
The consensus statement was proposed by the chairpersons in the session, Dr Eivind Berge, Olso and Associate Professor Andreas TÚrent, Uppsala, 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 Bj÷rn Dahl÷f, G÷teborg, Professor Kennedy R Lees, Glasgow, Associate Professor Andreas TÚrent, Uppsala and Professor Laura Fratiglione
Consensus statement: Blood pressure control and secondary stroke prevention:
What recommendation could be given for blood pressure lowering after stroke and TIA?
1. Overall evidence: There are now studies (the PROGRESS trial and a systematic review in Stroke 2003), which clearly show that lowering of blood pressure is effective, not only in primary prevention, but also in secondary prevention after stroke and TIA (Grade A evidence).
2. Effect: The PROGRESS trial, including 6105 patients, demonstrated that an ACE inhibitor and a diuretic, mainly in combination, are beneficial after ischemic and hemorrhagic stroke. The relative risk of stroke is reduced by 28 %, and the relative risk of major cardiac events by 26 % over 4 years (Grade B evidence).
3. Safety: The regimen given to PROGRESS patients was safe and well tolerated: 10% stopped taking study drug during a four-week screening period for tolerance. Thereafter, only 1 % more patients stopped active therapy because of hypotension. In addition, the risk of dementia and cognitive decline was reduced by active therapy, probably due to a lower risk of a second stroke (Grade B evidence).
4. Target blood pressure: The target level of blood pressure control has not been precisely defined by PROGRESS, though benefit was present in hypertensive (mean 159/94 mmg Hg) as well as normotensive stroke patients (mean 136/79 mm Hg). In an overview of published reviews (Stroke 2004), it appears that the lower the pressure, the lower the risk of stroke (Grade B evidence).
5. Age: Evidence of a beneficial effect of antihypertensive drug therapy emerges from a sample of relatively young stroke patients (PROGRESS, mean age 64 ▒10 years). In clinical practice, blood pressure lowering should now be considered in all patients below 75 years of age after stroke and TIA (Grade B evidence). Since there is no direct evidence from patients older than 75 years, it seems right to give such treatment to the oldest patients on an individual basis only.
6. Drugs: The only direct evidence of blood pressure lowering after stroke and TIA is for diuretics and ACE-inhibitors (the PROGRESS trial and a systematic review in Stroke 2003) (Grade A evidence). However, it may be that other blood pressure lowering agents are as effective provided that the blood pressure reduction is substantial (~10/5 mm Hg) and long lasting (years).
7. Start of drug therapy: In PROGRESS, it was recommended that patients should be clinically stable for at least 2 weeks after their most recent vascular event. Most patients were included months after the qualifying event (median 8 months). In clinical practice it appears reasonable to start blood pressure lowering when the patientĺs condition has stabilized (Grade C evidence).
8. Acute blood pressure lowering: The value of blood pressure lowering drugs in the acute phase (< 2 weeks) is still unproven. An ARB was used in the ACCESS study, including 342 hypertensive patients (BP>160 systolic and >100 diastolic pressure) within 30 hours (median) after stroke. The number of deaths and vascular events were significantly fewer among ARB-treated patients at 1 year (Grade C evidence). These data have to be confirmed in a larger randomized controlled trial (RCT), before such treatment should be given in routine care.