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Ambulatory blood pressure in stroke and cognitive dysfunction
Antonio Coca1, Miguel Camafort, Mónica Doménech
1Hypertension and Vascular Risk Unit, Department of Internal Medicine, Institute of Medicine and Dermatology, Hospital Clínic (IDIBAPS), c/ Villarroel 170, 08036, Barcelona, Spain. acoca@clinic.ub.es
Insights
Ambulatory blood pressure monitoring (ABPM) reveals links between hypertension, white-coat hypertension, and brain damage, including stroke and cognitive decline. ABPM is crucial for understanding these complex relationships and guiding treatment.
Area of Science:
- Cardiology
- Neurology
- Hypertension Research
Background:
- Ambulatory blood pressure monitoring (ABPM) is increasingly recognized for its role in assessing blood pressure variability and its impact on cardiovascular and cerebrovascular health.
- Understanding the relationship between ABPM patterns and brain damage, including stroke and cognitive impairment, is crucial for effective hypertension management.
Purpose of the Study:
- To review current data on the utility of ABPM in relation to antihypertensive treatment for primary stroke prevention.
- To explore the association between ABPM parameters and brain damage, such as silent brain lesions and cognitive impairment.
- To examine the prognostic significance of different ABPM patterns in the acute stroke setting.
Main Methods:
- Review of large-scale clinical trials (Syst-Eur, HYVET) evaluating ABPM and antihypertensive treatment in stroke prevention.
- Analysis of data linking ABPM parameters (circadian patterns, variability) to stroke incidence, brain lesions, and cognitive function.
- Examination of ABPM findings in the acute stroke setting regarding cerebral edema and functional status.
Main Results:
- In primary stroke prevention, antihypertensive treatment effectively lowered ABPM in sustained isolated systolic hypertension but not in white-coat hypertension (WCH), which showed a lower stroke incidence.
- In the elderly, WCH was present in 50% of patients, and treatment still yielded a significant stroke reduction, questioning the benign nature of WCH in this population.
- In acute stroke, sustained high BP in the first 24 hours correlated with cerebral edema and poorer outcomes, while extreme nocturnal dipping (
Conclusions:
- ABPM provides valuable insights into the relationship between blood pressure, hypertension management, and brain damage, including stroke and cognitive impairment.
- White-coat hypertension may be benign in younger populations but not necessarily in the elderly.
- ABPM parameters like circadian patterns and nocturnal dipping status are associated with stroke outcomes and cognitive function, though causality requires further investigation.
Abstract:
We have reviewed the most relevant data regarding ABPM and brain damage, with specific reference to first and recurrent stroke, silent structural brain lesions such as lacunar infarcts and white matter lesions, and cognitive impairment. Only two large studies have evaluated the usefulness of ABPM in relation to antihypertensive treatment in primary stroke prevention. In the Syst-Eur trial, drug treatment reduced ABPM and office BP more than placebo in patients with sustained isolated systolic hypertension (ISH). In contrast, in those patients with white-coat hypertension (WCH) changes in ABPM between the treatment groups were not significantly different. Patients with WCH had a lower incidence of stroke (p < 0.05) during follow-up than patients with sustained ISH, suggesting that WCH is a benign condition. In the HYVET trial 50 % of the very elderly patients included with office systolic BP > 160 mmHg had WCH. However, a significant 30 % stroke reduction was observed in treated patients including those with WCH, indicating that WCH may not be a benign condition in the elderly. In the acute stroke setting, where treatment of hypertension is not routinely recommended due to the lack of evidence and the differing results of the very few available trials, ABPM data shows that sustained high BP during the first 24 h after acute stroke is related to the formation of cerebral edema and a poorer functional status. On the other hand, even when nondipping status was initially related to a poorer prognosis, data indicate that patients with very-large nocturnal dipping, the so-called "extreme dippers", are those with the worse outcomes after stroke. The association between different ABPM parameters (circadian pattern, short-term variability) and poorer performance scores in cognitive function tests have been reported, especially in elderly hypertensives. Unfortunately most of these studies were cross-sectional and the associations do not establish causality.
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