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Level of systolic blood pressure within the normal range and risk of recurrent stroke
Bruce Ovbiagele1, Hans-Christophe Diener, Salim Yusuf
1Department of Neurosciences, University of California, 9500 Gilman Dr, San Diego, CA 92093, USA. Ovibes@ucsd.edu
Insights
Maintaining very low systolic blood pressure (SBP) below 120 mm Hg or very high SBP above 150 mm Hg after a recent ischemic stroke increases the risk of recurrent stroke. Optimal SBP for stroke prevention appears to be in the high-normal range (130-140 mm Hg).
Area of Science:
- Neurology
- Cardiology
- Clinical Trials
Background:
- Recurrent stroke prevention guidelines advocate for significant systolic blood pressure (SBP) reduction, defining normal SBP as less than 120 mm Hg.
- The impact of maintaining very low SBP on vascular event risk post-ischemic stroke remains unclear.
Purpose of the Study:
- To investigate the association between different systolic blood pressure (SBP) levels and the risk of recurrent stroke in patients with recent non-cardioembolic ischemic stroke.
Main Methods:
- A post hoc observational analysis of a multicenter trial involving 20,330 patients (age ≥50 years) with recent ischemic stroke.
- Patients were categorized into five SBP groups: very low-normal (<120 mm Hg), low-normal (120-<130 mm Hg), high-normal (130-<140 mm Hg), high (140-<150 mm Hg), and very high (≥150 mm Hg).
- Follow-up duration was 2.5 years, with primary outcome as recurrent stroke and secondary outcome as a composite of stroke, myocardial infarction, or vascular death.
Main Results:
- Recurrent stroke rates varied across SBP groups, with the very high SBP group showing the highest rate (14.1%).
- Compared to the high-normal SBP group (130-<140 mm Hg), patients in the very low-normal (<120 mm Hg), high (140-<150 mm Hg), and very high (≥150 mm Hg) SBP groups had a significantly higher risk of recurrent stroke.
- Increased risk of the secondary composite outcome was also observed in the very low-normal, low-normal, high, and very high SBP groups compared to the high-normal group.
Conclusions:
- Systolic blood pressure levels in the very low-normal (<120 mm Hg), high (140-<150 mm Hg), and very high (≥150 mm Hg) ranges are associated with an increased risk of recurrent stroke after a recent non-cardioembolic ischemic stroke.
- Maintaining SBP within the high-normal range (130-<140 mm Hg) may be associated with a lower risk of recurrent stroke and vascular events.
- These findings suggest a potential J-shaped or U-shaped relationship between SBP and stroke recurrence risk, challenging current guidelines on target SBP levels.
Context:
Recurrent stroke prevention guidelines suggest that larger reductions in systolic blood pressure (SBP) are positively associated with a greater reduction in the risk of recurrent stroke and define an SBP level of less than 120 mm Hg as normal. However, the association of SBP maintained at such levels with risk of vascular events after a recent ischemic stroke is unclear.
Objective:
To assess the association of maintaining low-normal vs high-normal SBP levels with risk of recurrent stroke.
Design, Setting, And Patients:
Post hoc observational analysis of a multicenter trial involving 20,330 patients (age ≥50 years) with recent non-cardioembolic ischemic stroke; patients were recruited from 695 centers in 35 countries from September 2003 through July 2006 and followed up for 2.5 years (follow-up ended on February 8, 2008). Patients were categorized based on their mean SBP level: very low-normal (<120 mm Hg), low-normal (120-<130 mm Hg), high-normal (130-<140 mm Hg), high (140-<150 mm Hg), and very high (≥150 mm Hg).
Main Outcome Measures:
The primary outcome was first recurrence of stroke of any type and the secondary outcome was a composite of stroke, myocardial infarction, or death from vascular causes.
Results:
The recurrent stroke rates were 8.0% (95% CI, 6.8%-9.2%) for the very low-normal SBP level group, 7.2% (95% CI, 6.4%-8.0%) for the low-normal SBP group, 6.8% (95% CI, 6.1%-7.4%) for the high-normal SBP group, 8.7% (95% CI, 7.9%-9.5%) for the high SBP group, and 14.1% (95% CI, 13.0%-15.2%) for the very high SBP group. Compared with patients in the high-normal SBP group, the risk of the primary outcome was higher for patients in the very low-normal SBP group (adjusted hazard ratio [AHR], 1.29; 95% CI, 1.07-1.56), in the high SBP group (AHR, 1.23; 95% CI, 1.07-1.41), and in the very high SBP group (AHR, 2.08; 95% CI, 1.83-2.37). Compared with patients in the high-normal SBP group, the risk of secondary outcome was higher for patients in the very low-normal SBP group (AHR, 1.31; 95% CI, 1.13-1.52), in the low-normal SBP group (AHR, 1.16; 95% CI, 1.03-1.31), in the high SBP group (AHR, 1.24; 95% CI, 1.11-1.39), and in the very high SBP group (AHR, 1.94; 95% CI, 1.74-2.16).
Conclusion:
Among patients with recent non-cardioembolic ischemic stroke, SBP levels during follow-up in the very low-normal (<120 mm Hg), high (140-<150 mm Hg), or very high (≥150 mm Hg) range were associated with increased risk of recurrent stroke.
Trial Registration:
clinicaltrials.gov Identifier: NCT00153062.
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