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Antihypertensive therapy in the prevention of stroke: what, when and for whom?
1University Division of Medicine for the Elderly, The Glenfield Hospital, Leicester, England. martin.fotherby@glenfield-tr.trent.nhs.uk
Insights
Low dose thiazide diuretics effectively prevent stroke, especially in older adults and those with diabetes. Combination therapy is often needed for optimal blood pressure control to reduce stroke risk.
Area of Science:
- Cardiovascular Medicine
- Neurology
- Pharmacology
Background:
- Antihypertensive therapy is crucial for stroke prevention.
- Thiazide diuretics, ACE inhibitors, and calcium antagonists show efficacy in specific patient groups.
- Optimal blood pressure targets for stroke risk reduction are debated.
Purpose of the Study:
- To review the efficacy of various antihypertensive regimens for stroke prevention and management.
- To discuss combination therapy for achieving target blood pressure levels.
- To explore the role of antihypertensive treatment in the early and later post-stroke periods.
Main Methods:
- Review of existing clinical trial data and guidelines.
- Analysis of antihypertensive drug classes and their impact on blood pressure and stroke risk.
- Discussion of treatment strategies based on patient characteristics and stroke phase.
Main Results:
- Low-dose thiazide diuretics are effective for primary stroke prevention, particularly in the elderly.
- Combination therapy is necessary to achieve target blood pressure levels for maximal stroke risk reduction.
- Antihypertensive treatment in the early post-stroke period requires careful consideration due to spontaneous BP fluctuations.
Conclusions:
- Antihypertensive therapy plays a vital role in stroke prevention and reducing recurrence.
- Individualized treatment strategies are essential, considering patient comorbidities and the timing relative to stroke.
- Further research is needed to clarify optimal antihypertensive management in the acute and subacute phases post-stroke.
Abstract:
It is clear that antihypertensive regimens based on a low dose thiazide diuretic are effective for the primary prevention of stroke, particularly in older patients. In patients with diabetes mellitus who are at a higher risk of stroke, low dose thiazide diuretics and ACE inhibitors are of benefit. In those with isolated systolic hypertension, long-acting dihydropyridine calcium antagonists, in addition tolow dose thiazide diuretics, have also been shown to significantly reduce stroke risk. However, to attain sufficient lowering of blood pressure (BP) to most effectively reduce the risk of stroke (i.e. to levels of 140-150/80-85 mm Hg or lower and perhaps to <140/<80 mm Hg in patients with diabetes mellitus) combination therapy will be required. Immediately following stroke BP tends to fall spontaneously and therapy is probably not required in the great majority of patients during the first few days poststroke. If treatment is required shortly after this period, agents with a slow and gentle onset of action appear to be preferable; some preliminary data suggest that ACE inhibitors, despite lowering systemic BP, have no significant effect on cerebral blood flow. However, there is little clinical outcome data to clearly define the role of antihypertensive treatment in the early poststroke period. Whether existing antihypertensive therapy should be continued following stroke is also unclear, but such decisions may be influenced by factors such as the actual BP level, other indications for treatment (e.g. angina pectoris or cardiac failure) or the presence of dysphagia. There is more evidence to suggest that, some weeks to months following stroke (particularly a minor stroke), lower rather than higher BP is favourable, and better control of high BP with therapy reduces stroke recurrence.