Hypertension is a leading risk factor for stroke. Treating hypertension reduces the risk of stroke through several mechanisms. All classes of antihypertensive drugs lower stroke risk, though some are preferred for primary and secondary stroke prevention. Maintaining controlled blood pressure reduces first and recurrent strokes, highlighting the importance of adherence to antihypertensive regimens. Guidelines recommend targeting a blood pressure of less than 130/80 mmHg to minimize stroke risk, especially for those with additional risk factors.

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