Effect of Antihypertensive Drug Classes on Stroke Prevention: A Systematic Review and Meta-Analysis

Hypertension is the most common modifiable risk factor for stroke. However, whether different classes of antihypertensive drugs provide equal protection against stroke remains controversial. This review aimed to systematically compare the effects of various antihypertensive drug classes on stroke prevention through a contemporary meta-analysis of randomized controlled trials (RCTs). Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a literature search was conducted in PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Scopus for studies published since January 2000. Eligible RCTs compared angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), beta-blockers (BBs), calcium channel blockers (CCBs), or diuretics with another drug class or placebo and reported stroke incidence. Data were pooled using a random-effects model. Subgroup analyses were performed based on prevention type, baseline risk, and differences in achieved blood pressure. A total of 10 RCTs (N=180,342 participants) were included. The pooled meta-analysis showed no statistically significant difference in stroke risk among the drug classes (risk ratio (RR): 0.94; 95% confidence interval (CI): 0.83-1.05), although heterogeneity was substantial (I²=65%). Subgroup analyses revealed no effect modification by prevention type or baseline risk. However, studies with a moderate to significant between-group difference in systolic blood pressure (SBP) (>2 mmHg) demonstrated a substantial reduction in stroke risk (RR: 0.78; 95% CI: 0.71-0.85), whereas studies with a minimal difference (<2 mmHg) did not (RR: 1.02: 95% CI: 0.90-1.14; p for subgroup difference=0.001). No antihypertensive drug class was found to be superior for stroke prevention overall. The magnitude of achieved SBP reduction, rather than the drug class itself, appears to be the primary determinant of benefit.