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Addressing Hypertension to Reduce the
Burden of Stroke
Dr. Sudhir Kumar MD DM
Consultant Neurologist
Apollo Hospitals, Hyderabad
Contents
• What is stroke
• Prevalence and burden of stroke
• Stroke outcomes
• Risk factors for stroke
• Stroke prevention
– Antihypertensive treatment in primary stroke prevention
– Antihypertensive treatment in secondary stroke prevention
• Conclusions
2
What is stroke
• Stroke occurs when the blood supply to an area in
the brain is blocked leading to brain tissue damage
• Ischemic stroke
– Caused by blood clots or fatty plaques blocking
vessels in the brain; accounts for ~70% of all stroke
cases
• Hemorrhagic stroke
– Caused by rupture of blood vessels in the brain,
generally due to high blood pressure (most
commonly) or brain aneurysms (occasionally)
Hatano S, 1976 3
WHO definition of stroke1
“Rapidly developing clinical signs of focal (or global in case of coma) disturbance of
cerebral function lasting more than 24 hours or leading to death with no apparent
cause other than a vascular origin”
Stroke is a Major Cause of Death Globally
• According to the World Health Organization, stroke accounted for 11.1% of all
deaths in 2015; which is a little more than 6 million deaths of the total 56.4
million deaths.
WHO, 2015 4
The 10 leading causes of death in the world, 2015
Global Prevalence of Ischemic Stroke in 2013
Feigin VL et al, 2015 5
Global Ischemic Stroke-Related Mortality in 2013
Feigin VL et al, 2015 6
Global Burden of Stroke
• In 2013, there were
– 25.7 million stroke survivors
– 65 million deaths due to stroke
– 10.3 million new cases of stroke
– 113 million DALYs due to stroke
• >50% of the stroke burden was
attributed to ischemic stroke
• A majority of the stroke burden
was observed in developing
countries
– ~75% of all stroke-related
deaths
– >80% of DALYs lost
Feigin VL et al, 2015 7
DALYs, disability-adjusted life years
Ischemic Stroke
Hemorrhagic Stroke
Prevalence of stroke in India
1. Kamalakannan S et al, 2017
2. Banerjee TK and Das SK, 2016
8
• A systematic review of population-based,
cross-sectional, and cohort studies on
stroke in India reported1
– Cumulative incidence ranging from 105
to 150/100,000 persons/year
– Crude prevalence ranging from 44.29 to
559/100,000 persons
– Higher incidence and prevalence
compared to high income countries
• Ischemic stroke is more common when
compared to hemorrhagic stroke2
0
20
40
60
80
100
Ischemic stroke Hemorrhagic
stroke
% 20-32%
68-80%
Stroke subtypes2
19%
36%
0
10
20
30
40
2001-2003 2030
%ofAllDeaths
Year
Death due to CV causes and stroke2
CV, cardiovascular
Burden of stroke in India
1. Banerjee TK and Das SK, 2016
2. Pandian JD and Sudhan P, 2013
9
• Stroke is one of the leading causes of death in India
• 20-30% deaths occur within the first 10 days after stroke
• Disability-adjusted life years lost due to stroke are estimated to range from
597 to 795/100,000 person-years
• A high proportion of young people (<40 years) are affected by stroke in India
0
10
20
30
40
50
Mumbai Trivandrum Kolkata Bangalore
%
28-Day Case Fatality Rate in Indian Cities1,2
Stroke Outcomes
• 55-70% of stroke survivors become fully
independent by 1 year; 7-15% are
completely disabled1
• Among those with speech dysfunction
due to stroke, complete recovery was
reported in <50% of the cases1
• Early fatality after stroke is high1
• Although less common, stroke in
young adults has a disproportionately
large economic impact2
– Owing to disability in productive years
1. Banerjee TK and Das SK, 2016
2. Smajlović D, 2015
10
70%
20%
0
20
40
60
80
Index stroke Recurrent
stroke
%ofDeaths
Early Death Post-stroke
28-Day Post-stroke Disability in Indian Cities
Pandian JD and Sudhan P, 2013 11
Stroke Outcomes Can Be Improved: Act ‘FAST’
12
Risk Factors for Stroke
Stroke.org.uk 13
AF, atrial fibrillation; HRT, hormone replacement therapy; TIA, transient ischemic attack
Stroke Prevention
• Targeted interventions
that reduce blood
pressure and smoking,
and promote physical
activity and a healthy
diet, could substantially
reduce the burden
of stroke1
• Improving public
awareness, transportation
and access to health care
facilities are also crucial to
the management of
stroke2
1. O'Donnell MJ et al, 2010
2. Banerjee TK and Das SK, 2016
14
Hypertension: A Major Risk Factor for Stroke
• Hypertension, defined as systolic BP ≥140 mm Hg or diastolic BP ≥90
mm Hg, is a leading global health concern and a major risk factor for
most ischemic and hemorrhagic strokes1,2
• Two-thirds of the patients experiencing a first stroke have high BP
(≥160/90 mm Hg)3
• 10 mm Hg drop in systolic blood pressure equates to 41% reduction in
stroke risk
1. CDC, 2016
2. Gorelick PB and Aiyagari V, 2013
3. Hellerman JP, 1997
15
10 mm Hg
=
41%
BP, blood pressure
Management of Hypertension to Prevent Stroke
• The association between hypertension and stroke risk is
continuous1
• Prehypertension, defined as SBP 120-139 mm Hg or DBP 80-89
mm Hg, is being recognized as a stage for early intervention to
prevent stroke1,2
• Research show that a 12-13 mm Hg reduction in SBP could
reduce the number of strokes by 37%2
• Reduction in blood pressure is associated with reduced stroke
risk; all antihypertensive medications have a similar effect in
lowering stroke risk1
– The degree of blood pressure lowering is critical
1. Pedelty L and Gorelick PB, 2006
2. CDC, 2016
16
DBP, diastolic blood pressure; SBP, systolic blood pressure
Choice of antihypertensive
to prevent recurrent stroke
• Risk of recurrent stroke is heightened by presence of elevated BP…
Reduction in BP is important
• Meta-analysis of randomized controlled trials have demonstrated a 30%-
40% reduction of stroke with BP management
• If diuretic and ACE inhibitor or ARB treatment do not achieve BP target,
other agents, such as CCB and/or MRA may be added.
Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Hypertension. 2017
BP Lowering Reduces Risk of Stroke
• Blood pressure lowering of 10/5 mm Hg (SBP/DBP) was associated with a
reductions in risk of stroke
– 41% reduction in clinical trials
– 36% reduction in cohort studies
Law MR et al, 2009 18
CI, confidence interval; DBP, diastolic blood pressure; SBP, systolic blood pressure
Effect of Antihypertensive Drugs on Stroke Risk
• All 5 classes of antihypertensive drugs produced similar reductions in
incidence of stroke
• The reduction in incidence of stroke was smaller with -blockers (17%)
compared to other drug classes combined (29%; p=0.03)
Law MR et al, 2009 19
CI, confidence interval
PREFERRED ANTIHYPERTENSIVE DRUGS FOR SECONDARY STROKE
PREVENTION
CLASS OF DRUG DRUG EFFICACY
ACE inhibitor Perindopril, Ramipril Effective
Diuretic Indapamide Effective
ARB Losartan Effective
ARB Telmisartan Possibly Effective
Ca channel blocker Amlodipine Effective
Beta blocker Atenolol Not effective
Effect of Pre-treatment BP Level on Stroke Risk
Reduction
• A greater risk reduction
was observed in trials
with highest pre-
treatment diastolic BP
(≥95 mm Hg); likely due
more intensive
treatments in these trials
• Similar results observed
for higher pre-treatment
systolic BP
Law MR et al, 2009 21
BP, blood pressure; CI, confidence interval
Secondary Prevention of Stroke
• Preventing stroke recurrence is a major concern for practitioners
treating patients with stroke1
• Standard secondary stroke prevention treatment may consist of
an antiplatelet agent, a lipid lowering drug mainly HMG-CoA
reductase inhibitors (statins), and an antihypertensive agent2
• Early initiation of treatments for secondary stroke prevention is
associated with an 80% reduction in risk of early recurrent stroke2
• Targeting hypertension carries the highest benefit in reducing
stroke burden on a population level1
1. Esenwa C and Gutierrez J, 2015
2. Pandian JD and Sudhan P, 2013
22
HMG-CoA, 3-Hydroxy-3-Methyl-Glutaryl-Coenzyme A
23
Reduction in total stroke with Perindopril ± Indapamide
Riskreduction(%)
0 1 2 3 4 Years
Placebo group
Perindopril ± Indapamide
PROGRESS collaborative group. Lancet 2001;358:1033-41.
95%CI 17-38%
N=6105
p<0.0001
28% risk
reduction
Persistent Use of Antihypertensive Drugs Reduces
Stroke Recurrence
OR (95% CI)
Outcomes at 1 year Event rates Crude Adjusted
*
Stroke recurrence
Low persistence (<75%) 1150 (20.0%) Reference Reference
High persistence (≥75%) 364 (13.7%) 0.63 (0.56–0.72) 0.78 (0.68–0.89)
Combined vascular
events
Low persistence (<75%) 1510 (26.3%) Reference Reference
High persistence (≥75%) 433(16.3%) 0.55 (0.49–0.62) 0.71 (0.63–0.81)
Death
Low persistence (<75%) 1056 (18.4%) Reference Reference
High persistence (≥75%) 154 (5.8%) 0.27 (0.23–0.33) 0.44 (0.36–0.53)
Xu J et al, 2013 24
aAdjusted for age, level of education, monthly household income, marital status, history of stroke, myocardial
infarction, atrial fibrillation, diabetes mellitus, antihypertensive medication history, class of prescribed
antihypertensive drug at discharge, severity of stroke on admission, dysphagia, co-medication at discharge
(antiplatelet agents, anticoagulants, lipid-lowering agents and anti-diabetic medications).
BP TARGETS FOR STROKE PREVENTION
• <140/90 mmHg for uncomplicated hypertensive
patients,
• <130/80 mmHg for those with diabetes mellitus
or chronic kidney disease.
• <130/80 mmHg for those with recent lacunar
stroke.
Hypertension and Stroke in Guidelines
1. Gabb GM et al 2016
2. Whelton PK et al., 2017
3.Alexander A et al., 2017
26
NHFA 20161
All first-line anti-
hypertensive
agents are
recommended in
patients with
stroke
CHEP 20173
ACEI and
thiazide/thiazide-
like diuretic
combination is
preferred after
acute ischemic
stroke
ACC/AHA 20172
Thiazide diuretic,
ACEI, or ARB, or
combination of
thiazide diuretic
plus ACEI, is useful
ACC, American College of Cardiology; ACEI, Angiotensin Converting Enzyme Inhibitors; AHA, American Heart Association; ARB,
Angiotensin II receptor blockers; CHEP, Canadian Hypertension Education Program; NHFA, National Heart Foundation of Australia
Conclusions
• Stroke is the leading cause of death worldwide
• Primary prevention strategies, targeting modifiable risk factors,
are aimed at reducing the morbidity and mortality associated
with stroke
• Hypertension is a major risk factor for stroke incidence
• Antihypertensive therapy substantially reduces the risk of any
type of stroke, as well as stroke-related death and disability
27
28

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Addressing hypertension to reduce the burden of stroke 19 feb2018 (1)

  • 1. Addressing Hypertension to Reduce the Burden of Stroke Dr. Sudhir Kumar MD DM Consultant Neurologist Apollo Hospitals, Hyderabad
  • 2. Contents • What is stroke • Prevalence and burden of stroke • Stroke outcomes • Risk factors for stroke • Stroke prevention – Antihypertensive treatment in primary stroke prevention – Antihypertensive treatment in secondary stroke prevention • Conclusions 2
  • 3. What is stroke • Stroke occurs when the blood supply to an area in the brain is blocked leading to brain tissue damage • Ischemic stroke – Caused by blood clots or fatty plaques blocking vessels in the brain; accounts for ~70% of all stroke cases • Hemorrhagic stroke – Caused by rupture of blood vessels in the brain, generally due to high blood pressure (most commonly) or brain aneurysms (occasionally) Hatano S, 1976 3 WHO definition of stroke1 “Rapidly developing clinical signs of focal (or global in case of coma) disturbance of cerebral function lasting more than 24 hours or leading to death with no apparent cause other than a vascular origin”
  • 4. Stroke is a Major Cause of Death Globally • According to the World Health Organization, stroke accounted for 11.1% of all deaths in 2015; which is a little more than 6 million deaths of the total 56.4 million deaths. WHO, 2015 4 The 10 leading causes of death in the world, 2015
  • 5. Global Prevalence of Ischemic Stroke in 2013 Feigin VL et al, 2015 5
  • 6. Global Ischemic Stroke-Related Mortality in 2013 Feigin VL et al, 2015 6
  • 7. Global Burden of Stroke • In 2013, there were – 25.7 million stroke survivors – 65 million deaths due to stroke – 10.3 million new cases of stroke – 113 million DALYs due to stroke • >50% of the stroke burden was attributed to ischemic stroke • A majority of the stroke burden was observed in developing countries – ~75% of all stroke-related deaths – >80% of DALYs lost Feigin VL et al, 2015 7 DALYs, disability-adjusted life years Ischemic Stroke Hemorrhagic Stroke
  • 8. Prevalence of stroke in India 1. Kamalakannan S et al, 2017 2. Banerjee TK and Das SK, 2016 8 • A systematic review of population-based, cross-sectional, and cohort studies on stroke in India reported1 – Cumulative incidence ranging from 105 to 150/100,000 persons/year – Crude prevalence ranging from 44.29 to 559/100,000 persons – Higher incidence and prevalence compared to high income countries • Ischemic stroke is more common when compared to hemorrhagic stroke2 0 20 40 60 80 100 Ischemic stroke Hemorrhagic stroke % 20-32% 68-80% Stroke subtypes2 19% 36% 0 10 20 30 40 2001-2003 2030 %ofAllDeaths Year Death due to CV causes and stroke2 CV, cardiovascular
  • 9. Burden of stroke in India 1. Banerjee TK and Das SK, 2016 2. Pandian JD and Sudhan P, 2013 9 • Stroke is one of the leading causes of death in India • 20-30% deaths occur within the first 10 days after stroke • Disability-adjusted life years lost due to stroke are estimated to range from 597 to 795/100,000 person-years • A high proportion of young people (<40 years) are affected by stroke in India 0 10 20 30 40 50 Mumbai Trivandrum Kolkata Bangalore % 28-Day Case Fatality Rate in Indian Cities1,2
  • 10. Stroke Outcomes • 55-70% of stroke survivors become fully independent by 1 year; 7-15% are completely disabled1 • Among those with speech dysfunction due to stroke, complete recovery was reported in <50% of the cases1 • Early fatality after stroke is high1 • Although less common, stroke in young adults has a disproportionately large economic impact2 – Owing to disability in productive years 1. Banerjee TK and Das SK, 2016 2. Smajlović D, 2015 10 70% 20% 0 20 40 60 80 Index stroke Recurrent stroke %ofDeaths Early Death Post-stroke
  • 11. 28-Day Post-stroke Disability in Indian Cities Pandian JD and Sudhan P, 2013 11
  • 12. Stroke Outcomes Can Be Improved: Act ‘FAST’ 12
  • 13. Risk Factors for Stroke Stroke.org.uk 13 AF, atrial fibrillation; HRT, hormone replacement therapy; TIA, transient ischemic attack
  • 14. Stroke Prevention • Targeted interventions that reduce blood pressure and smoking, and promote physical activity and a healthy diet, could substantially reduce the burden of stroke1 • Improving public awareness, transportation and access to health care facilities are also crucial to the management of stroke2 1. O'Donnell MJ et al, 2010 2. Banerjee TK and Das SK, 2016 14
  • 15. Hypertension: A Major Risk Factor for Stroke • Hypertension, defined as systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg, is a leading global health concern and a major risk factor for most ischemic and hemorrhagic strokes1,2 • Two-thirds of the patients experiencing a first stroke have high BP (≥160/90 mm Hg)3 • 10 mm Hg drop in systolic blood pressure equates to 41% reduction in stroke risk 1. CDC, 2016 2. Gorelick PB and Aiyagari V, 2013 3. Hellerman JP, 1997 15 10 mm Hg = 41% BP, blood pressure
  • 16. Management of Hypertension to Prevent Stroke • The association between hypertension and stroke risk is continuous1 • Prehypertension, defined as SBP 120-139 mm Hg or DBP 80-89 mm Hg, is being recognized as a stage for early intervention to prevent stroke1,2 • Research show that a 12-13 mm Hg reduction in SBP could reduce the number of strokes by 37%2 • Reduction in blood pressure is associated with reduced stroke risk; all antihypertensive medications have a similar effect in lowering stroke risk1 – The degree of blood pressure lowering is critical 1. Pedelty L and Gorelick PB, 2006 2. CDC, 2016 16 DBP, diastolic blood pressure; SBP, systolic blood pressure
  • 17. Choice of antihypertensive to prevent recurrent stroke • Risk of recurrent stroke is heightened by presence of elevated BP… Reduction in BP is important • Meta-analysis of randomized controlled trials have demonstrated a 30%- 40% reduction of stroke with BP management • If diuretic and ACE inhibitor or ARB treatment do not achieve BP target, other agents, such as CCB and/or MRA may be added. Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Hypertension. 2017
  • 18. BP Lowering Reduces Risk of Stroke • Blood pressure lowering of 10/5 mm Hg (SBP/DBP) was associated with a reductions in risk of stroke – 41% reduction in clinical trials – 36% reduction in cohort studies Law MR et al, 2009 18 CI, confidence interval; DBP, diastolic blood pressure; SBP, systolic blood pressure
  • 19. Effect of Antihypertensive Drugs on Stroke Risk • All 5 classes of antihypertensive drugs produced similar reductions in incidence of stroke • The reduction in incidence of stroke was smaller with -blockers (17%) compared to other drug classes combined (29%; p=0.03) Law MR et al, 2009 19 CI, confidence interval
  • 20. PREFERRED ANTIHYPERTENSIVE DRUGS FOR SECONDARY STROKE PREVENTION CLASS OF DRUG DRUG EFFICACY ACE inhibitor Perindopril, Ramipril Effective Diuretic Indapamide Effective ARB Losartan Effective ARB Telmisartan Possibly Effective Ca channel blocker Amlodipine Effective Beta blocker Atenolol Not effective
  • 21. Effect of Pre-treatment BP Level on Stroke Risk Reduction • A greater risk reduction was observed in trials with highest pre- treatment diastolic BP (≥95 mm Hg); likely due more intensive treatments in these trials • Similar results observed for higher pre-treatment systolic BP Law MR et al, 2009 21 BP, blood pressure; CI, confidence interval
  • 22. Secondary Prevention of Stroke • Preventing stroke recurrence is a major concern for practitioners treating patients with stroke1 • Standard secondary stroke prevention treatment may consist of an antiplatelet agent, a lipid lowering drug mainly HMG-CoA reductase inhibitors (statins), and an antihypertensive agent2 • Early initiation of treatments for secondary stroke prevention is associated with an 80% reduction in risk of early recurrent stroke2 • Targeting hypertension carries the highest benefit in reducing stroke burden on a population level1 1. Esenwa C and Gutierrez J, 2015 2. Pandian JD and Sudhan P, 2013 22 HMG-CoA, 3-Hydroxy-3-Methyl-Glutaryl-Coenzyme A
  • 23. 23 Reduction in total stroke with Perindopril ± Indapamide Riskreduction(%) 0 1 2 3 4 Years Placebo group Perindopril ± Indapamide PROGRESS collaborative group. Lancet 2001;358:1033-41. 95%CI 17-38% N=6105 p<0.0001 28% risk reduction
  • 24. Persistent Use of Antihypertensive Drugs Reduces Stroke Recurrence OR (95% CI) Outcomes at 1 year Event rates Crude Adjusted * Stroke recurrence Low persistence (<75%) 1150 (20.0%) Reference Reference High persistence (≥75%) 364 (13.7%) 0.63 (0.56–0.72) 0.78 (0.68–0.89) Combined vascular events Low persistence (<75%) 1510 (26.3%) Reference Reference High persistence (≥75%) 433(16.3%) 0.55 (0.49–0.62) 0.71 (0.63–0.81) Death Low persistence (<75%) 1056 (18.4%) Reference Reference High persistence (≥75%) 154 (5.8%) 0.27 (0.23–0.33) 0.44 (0.36–0.53) Xu J et al, 2013 24 aAdjusted for age, level of education, monthly household income, marital status, history of stroke, myocardial infarction, atrial fibrillation, diabetes mellitus, antihypertensive medication history, class of prescribed antihypertensive drug at discharge, severity of stroke on admission, dysphagia, co-medication at discharge (antiplatelet agents, anticoagulants, lipid-lowering agents and anti-diabetic medications).
  • 25. BP TARGETS FOR STROKE PREVENTION • <140/90 mmHg for uncomplicated hypertensive patients, • <130/80 mmHg for those with diabetes mellitus or chronic kidney disease. • <130/80 mmHg for those with recent lacunar stroke.
  • 26. Hypertension and Stroke in Guidelines 1. Gabb GM et al 2016 2. Whelton PK et al., 2017 3.Alexander A et al., 2017 26 NHFA 20161 All first-line anti- hypertensive agents are recommended in patients with stroke CHEP 20173 ACEI and thiazide/thiazide- like diuretic combination is preferred after acute ischemic stroke ACC/AHA 20172 Thiazide diuretic, ACEI, or ARB, or combination of thiazide diuretic plus ACEI, is useful ACC, American College of Cardiology; ACEI, Angiotensin Converting Enzyme Inhibitors; AHA, American Heart Association; ARB, Angiotensin II receptor blockers; CHEP, Canadian Hypertension Education Program; NHFA, National Heart Foundation of Australia
  • 27. Conclusions • Stroke is the leading cause of death worldwide • Primary prevention strategies, targeting modifiable risk factors, are aimed at reducing the morbidity and mortality associated with stroke • Hypertension is a major risk factor for stroke incidence • Antihypertensive therapy substantially reduces the risk of any type of stroke, as well as stroke-related death and disability 27
  • 28. 28

Editor's Notes

  1. Reference Hatano S. Experience from a multicentre stroke register: a preliminary report. Bulletin of the World Health Organisation. 1976;54(5):541–553. 
  2. Reference World Health Organization. Global Health Estimates Technical Paper. Available at: http://www.who.int/healthinfo/global_burden_disease/GlobalCOD_method_2000_2015.pdf?ua=1
  3. Reference Feigin VL, Krishnamurthi RV, Parmar P, et al; GBD 2013 Writing Group; GBD 2013 Stroke Panel Experts Group. Update on the Global Burden of Ischemic and Hemorrhagic Stroke in 1990-2013: The GBD 2013 Study. Neuroepidemiology. 2015;45(3):161-76.
  4. Reference Feigin VL, Krishnamurthi RV, Parmar P, et al; GBD 2013 Writing Group; GBD 2013 Stroke Panel Experts Group. Update on the Global Burden of Ischemic and Hemorrhagic Stroke in 1990-2013: The GBD 2013 Study. Neuroepidemiology. 2015;45(3):161-76.
  5. Reference Feigin VL, Krishnamurthi RV, Parmar P, et al; GBD 2013 Writing Group; GBD 2013 Stroke Panel Experts Group. Update on the Global Burden of Ischemic and Hemorrhagic Stroke in 1990-2013: The GBD 2013 Study. Neuroepidemiology. 2015;45(3):161-76.
  6. References Kamalakannan S, Gudlavalleti ASV, Gudlavalleti VSM, et al. Incidence & prevalence of stroke in India: A systematic review. Indian J Med Res. 2017;146(2):175-185. Banerjee TK, Das SK. Fifty years of stroke researches in India. Ann Indian Acad Neurol. 2016 Jan-Mar;19(1):1-8.
  7. References Banerjee TK, Das SK. Fifty years of stroke researches in India. Ann Indian Acad Neurol. 2016 Jan-Mar;19(1):1-8. Pandian JD, Sudhan P. Stroke epidemiology and stroke care services in India. J Stroke. 2013 Sep;15(3):128-34.
  8. References Banerjee TK, Das SK. Fifty years of stroke researches in India. Ann Indian Acad Neurol. 2016;19(1):1-8. Smajlović D. Strokes in young adults: epidemiology and prevention. Vasc Health Risk Manag. 2015;11:157-64.
  9. Reference Pandian JD, Sudhan P. Stroke epidemiology and stroke care services in India. J Stroke. 2013 Sep;15(3):128-34.
  10. Reference http://www.wschronicle.com/2017/11/commentary-dont-forget-think-f-s-t/
  11. Key Points Modifiable risk factors for stroke include: Hypertension, diabetes mellitus, obesity, smoking, and dyslipidemia Nonmodifiable risk factors for stroke include: Age, family history or ethnicity,
  12. References O'Donnell MJ, Xavier D, Liu L, et al; INTERSTROKE investigators. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study. Lancet. 2010;376(9735):112-23. Banerjee TK, Das SK. Fifty years of stroke researches in India. Ann Indian Acad Neurol. 2016 Jan-Mar;19(1):1-8.
  13. References https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_state_hbp.htm Gorelick PB, Aiyagari V. The management of hypertension for an acute stroke: what is the blood pressure goal? Curr Cardiol Rep. 2013;15(6):366. doi: 10.1007/s11886-013-0366-2. Hellermann JP, Goraya TY, Jacobsen SJ, et al. Incidence of Heart Failure after Myocardial Infarction: Is It Changing over Time? Arch Intern Med 1997;157:2413–46. http://www.wschronicle.com/2017/11/commentary-dont-forget-think-f-s-t/
  14. References Pedelty L, Gorelick PB. Update on the management of hypertension to prevent stroke. Curr Treat Options Neurol. 2006 Nov;8(6):486-95. https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_state_hbp.htm
  15. Key points Objectives To determine the quantitative efficacy of different classes of blood pressure lowering drugs in preventing coronary heart disease (CHD) and stroke, and who should receive treatment. Study selection Randomised trials of blood pressure lowering drugs recording CHD events and strokes. 108 trials studied differences in blood pressure between study drug and placebo (or control group not receiving the study drug) (“blood pressure difference trials”), and 46 trials compared drugs (“drug comparison trials”). Seven trials with three randomised groups fell into both categories. The results were interpreted in the context of those expected from the largest published meta-analysis of cohort studies, totalling 958 000 people. Participants 464 000 people defined into three mutually exclusive categories: participants with no history of vascular disease, a history of CHD, or a history of stroke. Results In the blood pressure difference trials β blockers had a special effect over and above that due to blood pressure reduction in preventing recurrent CHD events in people with a history of CHD: risk reduction 29% (95% confidence interval 22% to 34%) compared with 15% (11% to 19%) in trials of other drugs. The extra effect was limited to a few years after myocardial infarction, with a risk reduction of 31% compared with 13% in people with CHD with no recent infarct (P=0.04). In the other blood pressure difference trials (excluding CHD events in trials of β blockers in people with CHD), there was a 22% reduction in CHD events (17% to 27%) and a 41% (33% to 48%) reduction in stroke for a blood pressure reduction of 10 mm Hg systolic or 5 mm Hg diastolic, similar to the reductions of 25% (CHD) and 36% (stroke) expected for the same difference in blood pressure from the cohort study meta-analysis, indicating that the benefit is explained by blood pressure reduction itself. The five main classes of blood pressure lowering drugs (thiazides, β blockers, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and calcium channel blockers) were similarly effective (within a few percentage points) in preventing CHD events and strokes, with the exception that calcium channel blockers had a greater preventive effect on stroke (relative risk 0.92, 95% confidence interval 0.85 to 0.98). The percentage reductions in CHD events and stroke were similar in people with and without cardiovascular disease and regardless of blood pressure before treatment (down to 110 mm Hg systolic and 70 mm Hg diastolic). Combining our results with those from two other studies (the meta-analyses of blood pressure cohort studies and of trials determining the blood pressure lowering effects of drugs according to dose) showed that in people aged 60-69 with a diastolic blood pressure before treatment of 90 mm Hg, three drugs at half standard dose in combination reduced the risk of CHD by an estimated 46% and of stroke by 62%; one drug at standard dose had about half this effect. The present meta-analysis also showed that drugs other than calcium channel blockers (with the exception of non-cardioselective β blockers) reduced the incidence of heart failure by 24% (19% to 28%) and calcium channel blockers by 19% (6% to 31%). Conclusions With the exception of the extra protective effect of β blockers given shortly after a myocardial infarction and the minor additional effect of calcium channel blockers in preventing stroke, all the classes of blood pressure lowering drugs have a similar effect in reducing CHD events and stroke for a given reduction in blood pressure so excluding material pleiotropic effects. The proportional reduction in cardiovascular disease events was the same or similar regardless of pretreatment blood pressure and the presence or absence of existing cardiovascular disease. Guidelines on the use of blood pressure lowering drugs can be simplified so that drugs are offered to people with all levels of blood pressure. Our results indicate the importance of lowering blood pressure in everyone over a certain age, rather than measuring it in everyone and treating it in some. Reference Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ. 2009 May 19;338:b1665.
  16. Key points Objectives To determine the quantitative efficacy of different classes of blood pressure lowering drugs in preventing coronary heart disease (CHD) and stroke, and who should receive treatment. Study selection Randomised trials of blood pressure lowering drugs recording CHD events and strokes. 108 trials studied differences in blood pressure between study drug and placebo (or control group not receiving the study drug) (“blood pressure difference trials”), and 46 trials compared drugs (“drug comparison trials”). Seven trials with three randomised groups fell into both categories. The results were interpreted in the context of those expected from the largest published meta-analysis of cohort studies, totalling 958 000 people. Participants 464 000 people defined into three mutually exclusive categories: participants with no history of vascular disease, a history of CHD, or a history of stroke. Results In the blood pressure difference trials β blockers had a special effect over and above that due to blood pressure reduction in preventing recurrent CHD events in people with a history of CHD: risk reduction 29% (95% confidence interval 22% to 34%) compared with 15% (11% to 19%) in trials of other drugs. The extra effect was limited to a few years after myocardial infarction, with a risk reduction of 31% compared with 13% in people with CHD with no recent infarct (P=0.04). In the other blood pressure difference trials (excluding CHD events in trials of β blockers in people with CHD), there was a 22% reduction in CHD events (17% to 27%) and a 41% (33% to 48%) reduction in stroke for a blood pressure reduction of 10 mm Hg systolic or 5 mm Hg diastolic, similar to the reductions of 25% (CHD) and 36% (stroke) expected for the same difference in blood pressure from the cohort study meta-analysis, indicating that the benefit is explained by blood pressure reduction itself. The five main classes of blood pressure lowering drugs (thiazides, β blockers, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and calcium channel blockers) were similarly effective (within a few percentage points) in preventing CHD events and strokes, with the exception that calcium channel blockers had a greater preventive effect on stroke (relative risk 0.92, 95% confidence interval 0.85 to 0.98). The percentage reductions in CHD events and stroke were similar in people with and without cardiovascular disease and regardless of blood pressure before treatment (down to 110 mm Hg systolic and 70 mm Hg diastolic). Combining our results with those from two other studies (the meta-analyses of blood pressure cohort studies and of trials determining the blood pressure lowering effects of drugs according to dose) showed that in people aged 60-69 with a diastolic blood pressure before treatment of 90 mm Hg, three drugs at half standard dose in combination reduced the risk of CHD by an estimated 46% and of stroke by 62%; one drug at standard dose had about half this effect. The present meta-analysis also showed that drugs other than calcium channel blockers (with the exception of non-cardioselective β blockers) reduced the incidence of heart failure by 24% (19% to 28%) and calcium channel blockers by 19% (6% to 31%). Conclusions With the exception of the extra protective effect of β blockers given shortly after a myocardial infarction and the minor additional effect of calcium channel blockers in preventing stroke, all the classes of blood pressure lowering drugs have a similar effect in reducing CHD events and stroke for a given reduction in blood pressure so excluding material pleiotropic effects. The proportional reduction in cardiovascular disease events was the same or similar regardless of pretreatment blood pressure and the presence or absence of existing cardiovascular disease. Guidelines on the use of blood pressure lowering drugs can be simplified so that drugs are offered to people with all levels of blood pressure. Our results indicate the importance of lowering blood pressure in everyone over a certain age, rather than measuring it in everyone and treating it in some. Reference Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ. 2009 May 19;338:b1665.
  17. Key points Objectives To determine the quantitative efficacy of different classes of blood pressure lowering drugs in preventing coronary heart disease (CHD) and stroke, and who should receive treatment. Study selection Randomised trials of blood pressure lowering drugs recording CHD events and strokes. 108 trials studied differences in blood pressure between study drug and placebo (or control group not receiving the study drug) (“blood pressure difference trials”), and 46 trials compared drugs (“drug comparison trials”). Seven trials with three randomised groups fell into both categories. The results were interpreted in the context of those expected from the largest published meta-analysis of cohort studies, totalling 958 000 people. Participants 464 000 people defined into three mutually exclusive categories: participants with no history of vascular disease, a history of CHD, or a history of stroke. Results In the blood pressure difference trials β blockers had a special effect over and above that due to blood pressure reduction in preventing recurrent CHD events in people with a history of CHD: risk reduction 29% (95% confidence interval 22% to 34%) compared with 15% (11% to 19%) in trials of other drugs. The extra effect was limited to a few years after myocardial infarction, with a risk reduction of 31% compared with 13% in people with CHD with no recent infarct (P=0.04). In the other blood pressure difference trials (excluding CHD events in trials of β blockers in people with CHD), there was a 22% reduction in CHD events (17% to 27%) and a 41% (33% to 48%) reduction in stroke for a blood pressure reduction of 10 mm Hg systolic or 5 mm Hg diastolic, similar to the reductions of 25% (CHD) and 36% (stroke) expected for the same difference in blood pressure from the cohort study meta-analysis, indicating that the benefit is explained by blood pressure reduction itself. The five main classes of blood pressure lowering drugs (thiazides, β blockers, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and calcium channel blockers) were similarly effective (within a few percentage points) in preventing CHD events and strokes, with the exception that calcium channel blockers had a greater preventive effect on stroke (relative risk 0.92, 95% confidence interval 0.85 to 0.98). The percentage reductions in CHD events and stroke were similar in people with and without cardiovascular disease and regardless of blood pressure before treatment (down to 110 mm Hg systolic and 70 mm Hg diastolic). Combining our results with those from two other studies (the meta-analyses of blood pressure cohort studies and of trials determining the blood pressure lowering effects of drugs according to dose) showed that in people aged 60-69 with a diastolic blood pressure before treatment of 90 mm Hg, three drugs at half standard dose in combination reduced the risk of CHD by an estimated 46% and of stroke by 62%; one drug at standard dose had about half this effect. The present meta-analysis also showed that drugs other than calcium channel blockers (with the exception of non-cardioselective β blockers) reduced the incidence of heart failure by 24% (19% to 28%) and calcium channel blockers by 19% (6% to 31%). Conclusions With the exception of the extra protective effect of β blockers given shortly after a myocardial infarction and the minor additional effect of calcium channel blockers in preventing stroke, all the classes of blood pressure lowering drugs have a similar effect in reducing CHD events and stroke for a given reduction in blood pressure so excluding material pleiotropic effects. The proportional reduction in cardiovascular disease events was the same or similar regardless of pretreatment blood pressure and the presence or absence of existing cardiovascular disease. Guidelines on the use of blood pressure lowering drugs can be simplified so that drugs are offered to people with all levels of blood pressure. Our results indicate the importance of lowering blood pressure in everyone over a certain age, rather than measuring it in everyone and treating it in some. Reference Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ. 2009 May 19;338:b1665.
  18. Reference Esenwa C, Gutierrez J. Secondary stroke prevention: challenges and solutions. Vasc Health Risk Manag. 2015 Aug 7;11:437-50. Pandian JD, Sudhan P. Stroke epidemiology and stroke care services in India. J Stroke. 2013 Sep;15(3):128-34.
  19. CI, confidence interval; OR, odds ratio Key Points: BACKGROUND: The efficacy of antihypertensive (AH) treatment after stroke has been investigated in several randomized clinical trials. However, non-adherence to AH medication is common for stroke patients in "real world" setting. The purpose of this study was to assess the impact of persistence with AH agents on ischemic stroke (IS) outcomes. METHODS AND RESULTS: Using the China National Stroke Registry, we analyzed data from 8409 IS patients with hypertension. Persistence with AH therapy (high persistence ≥75%, low persistence <75%) was measured by patient self-report at 3, 6, and 12 months after stroke. Multivariate logistic regression model was used to assess the relationship between persistence and IS outcomes (stroke recurrence, combined vascular events and death) at 12 months. Of the 8409 patients in this study, 40.0% were female and the mean age at study entry was 66.7 years. 31.6% of patients had high persistence with AH drugs, and 68.4% had low persistence during 1 year after stroke onset. High persistence with AH drugs significantly decreased the risk of stroke recurrence (odds ratio, 0.78; 95% CI, 0.68 to 0.89), combined vascular events (0.71; 0.63-0.81) and death (0.44; 0.36-0.53) compared with low persistence. CONCLUSIONS: Our study reinforces the benefits of AH medications in routine clinical practice and highlights the importance of persistence with AH therapy among IS patients known to be hypertensive within the first year of an event. Reference Xu J, Zhao X, Wang Y, et al. Impact of a better persistence with antihypertensive agents on ischemic stroke outcomes for secondary prevention. PLoS One. 2013;8(6):e65233.
  20. Reference 1. Gabb GM, Mangoni A, Anderson CS, Cowley D, Dowden JS, Golledge J, Hankey GJ, Howes FS, Leckie L, Perkovic V, Schlaich M. Guideline for the diagnosis and management of hypertension in adults—2016. mortality. 2016;3:4. 2. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2017;Nov 13: 3. Alexander A. et al. Hypertension Canada’s 2017 Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults. Can J Cardiol 2017; 33(5): 557-576.