Hypertension is a major risk factor for the first stroke as well as recurrent stroke. Therefore, adequate control of BP is necessary to reduce the risk of stroke recurrence. This presentation looks at the ABCD 2 score to predict the exact risk of stroke recurrence after TIA. Target BP that needs to be achieved has been discussed. Various antihypertensive agents based on the scientific evidence have been discussed.

1. Role ofRole of Blood PressureBlood Pressure
in Recurrent Strokein Recurrent Stroke
DR Sudhir Kumar MD DMDR Sudhir Kumar MD DM
Consultant NeurologistConsultant Neurologist
Apollo Hospitals, HyderabadApollo Hospitals, Hyderabad

2. HT AS A RISK FACTORHT AS A RISK FACTOR
FOR ACUTE ISCHEMICFOR ACUTE ISCHEMIC
STROKESTROKE
• People with HT are four times more likely to suffer
from stroke (as compared to those without HT),
• Higher the BP, higher is the risk of stroke (10mmHg
increase in SBP increases stroke risk by 38%),
• Lower BP reduces the risk of stroke, as compared to
mild HT (RR 0.50 at BP 136/84 mmHg, and 0.35 at
BP of 123/76 mmHg),
• HT is identified as a risk factor in about 66% of
patients with first ever ischemic stroke (either self-
reported history of HT or admission BP>160/90
mmHg).

3. Risk of stroke after a TIARisk of stroke after a TIA
• The risk of subsequent stroke after a TIA is 2% - 7%
within the first 90 days
• Higher ABCD2
scores are associated with greater risk of
stroke during the 2, 7, 30, and 90 days after a TIA
CMAJ, July 12, 2011, 183(10) & Johnston SC, et al. Lancet, , 2007 369:283-292
TIA - Transient Ischemic Attack

4. IMPACT OF HT ONIMPACT OF HT ON
ISCHEMIC STROKEISCHEMIC STROKE
SUBTYPESUBTYPE
• HT is the commonest risk factor for all stroke subtypes,
• HT is strongly associated with small artery occlusions and
lacunar infarcts,
• Hypertensive patients have more cerebral white matter
lesions on MRI. Presence of these findings predict a later
occurrence of ischemic stroke,
• Arteriosclerosis of penetrating brain vessels is involved in
the pathogenesis of white matter lesions.

5. ABCD 2 SCOREABCD 2 SCORE

7. Amarenco P et al.
N Engl J Med
2016;374:1533-42.

8. Role ofRole of BPBP in recurrentin recurrent
strokestroke
Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Hypertension. 2017
Evidence -
PROGRESS
Evidence -
PROGRESS

9. Choice ofChoice of
antihypertensiveantihypertensive
to prevent recurrentto prevent recurrent
strokestroke• 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

10. Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Hypertension. 2017

11. Risk Factors
Recommendation - Hypertension
Class/Level of
Evidence
BP reduction is recommended for both prevention of recurrent
stroke and prevention of other vascular events in persons who have
had an ischemic stroke or TIA and are beyond the first 24 hours
Class I;
LOE A
Becausethis benefit extends to persons with and without a
documented history ofhypertension, this recommendation is
reasonable for all patients withischemic stroke or TIA who are
considered appropriate for BP reduction
Class IIa;
LOE B
An absolute target BP level and reduction are uncertain and should
be individualized, but benefit has been associated with an average
reduction of approximately 10/5 mm Hg, and normal BPlevels have
been defined as <120/80 mm Hg by JNC
Class IIa;
LOE B
BP reductionBP reduction
in recurrent strokein recurrent stroke

12. BP TARGETS FORBP TARGETS FOR
STROKE PREVENTIONSTROKE 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.

13. Risk Factors
Recommendation - Hypertension
Class/Level of
Evidence
Several lifestyle modificationshave been associated with BP
reduction and are a reasonable part of a comprehensive
antihypertensive therapy.
These modifications include salt restriction; weight loss;
consumptionof a diet rich in fruits, vegetables, and low-fat dairy
products;regular aerobic physical activity; and limited alcohol
consumption.
Class IIa;
LOE C
Theoptimal drug regimen to achieve the recommended level of
reduction is uncertain because direct comparisons between
regimens are limited. The availabledata indicate that diuretics or
the combination of diuretics and an ACEI are useful
Class I;
LOE A
The choice of specificdrugs and targets should be individualized on
the basis of pharmacologic properties, mechanism of action, and
considerationof specific patient characteristics for which specific
agents are probably indicated (eg,extracranial cerebrovascular
occlusive disease, renal impairment, cardiac disease, and diabetes)
Class IIa;
LOE B

14. Post-stroke Antihypertensive Treatment Study (PATS) –
indapamide
Perindopril Protection Against Recurrent Stroke Study
(PROGRESS) – perindopril + indapamide
Journal of Stroke 2017;19(2):152-165.
Evidence inEvidence in
recurrent strokerecurrent stroke
preventionprevention

15. PREFERRED ANTIHYPERTENSIVE DRUGSPREFERRED ANTIHYPERTENSIVE DRUGS
FOR SECONDARY STROKE PREVENTIONFOR 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

16. Comments/queries?Comments/queries?