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Updated: Aug 18, 2026
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Managing the patient at risk for a second stroke
1State University of New York DownState College of Medicine, New York, USA. michaelwebermd@cs.com
Insights
Aggressive antihypertensive therapy, particularly angiotensin II receptor blockers (ARBs), effectively reduces stroke risk. ARBs may offer greater cerebrovascular protection than expected from blood pressure reduction alone.
Area of Science:
- Cardiology
- Neurology
- Pharmacology
Background:
- Cerebrovascular disease is a leading global cause of mortality, with increasing prevalence due to demographic shifts.
- Antihypertensive therapy, even with modest blood pressure reductions, significantly lowers stroke risk, benefiting even non-hypertensive individuals.
- Comparative trials highlight varying impacts of antihypertensive drug classes on cerebrovascular disease incidence, influencing therapeutic decisions for stroke risk factors.
Purpose of the Study:
- To investigate the differential effects of antihypertensive drug classes on cerebrovascular disease, focusing on the renin-angiotensin system.
- To evaluate the specific role of angiotensin II receptor blockers (ARBs) in reducing stroke risk beyond their blood pressure-lowering effects.
- To explore the clinical relevance of renin-angiotensin system receptor subtypes and the impact of morning blood pressure control on stroke incidence.
Main Methods:
- Analysis of comparative clinical trials examining antihypertensive therapies and their effects on cerebrovascular events.
- Review of evidence regarding angiotensin II receptor blockers (ARBs) versus angiotensin converting enzyme inhibitors (ACEIs) in stroke prevention.
- Consideration of preclinical data on angiotensin II receptor subtypes (AT1 and AT2) and ongoing large-scale trials (PRoFESS, ONTARGET).
Main Results:
- Evidence suggests ARBs may reduce first stroke risk more than expected solely from blood pressure reduction.
- The MOSES study indicated ARBs provide additional cardiovascular and cerebrovascular protection in hypertensive patients with prior stroke, beyond blood pressure control.
- Preclinical data suggest differential effects of AT1 and AT2 receptor activation, though clinical significance remains unknown.
Conclusions:
- Antihypertensive therapy is crucial for reducing cerebrovascular disease burden.
- ARBs show potential for superior stroke risk reduction compared to other antihypertensives, possibly through mechanisms beyond blood pressure lowering.
- Further research through ongoing trials is essential to clarify the role of specific drug classes and receptor pathways in cerebrovascular protection.
Abstract:
Cerebrovascular disease is a major cause of mortality world-wide, and the prevalence is expected to increase as a result of projected demographic trends. Aggressive antihypertensive therapy is one intervention that has proven highly effective in reducing the risk of stroke, with relatively small blood pressure reductions affording measurable benefit even in patients not conventionally considered hypertensive. Comparative clinical trials are revealing evidence of differential impacts of antihypertensive classes on the incidence of cerebrovascular disease that will probably be important for therapeutic choice in patients with risk factors for stroke. In particular, the role of the renin-angiotensin system in cerebrovascular disease has come under scrutiny as a result of evidence that angiotensin II receptor blockers (ARBs), but perhaps not angiotensin converting enzyme inhibitors, can reduce the risk of a first stroke to a greater degree than might be expected from their effects on blood pressure alone. Although preclinical evidence suggests that there are differential effects of the type 1 and type 2 receptor activation, the clinical relevance of this is not yet known. Furthermore, the effect on the incidence of stroke conferred by blood pressure control in the early morning hours - the time when the incidence of strokes peaks--has not been tested. Some evidence for the beneficial effect of an ARB on secondary stroke prevention comes from the MOrbidity and mortality after Stroke --Eprosartan compared with nitrendipine in Secondary prevention study (MOSES), which showed that the ARB protected against cerebro- and cardiovascular events in hypertensive patients with a previous stroke over and above the protection offered by blood pressure control. These hypotheses are among those being examined in two current large-scale trials: the Prevention Regimen For Effectively avoiding Second Strokes (PRoFESS), and The ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET) Trial Programme.
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