Lowering of Blood Pressure for Recurrent Stroke Prevention

Hypertension is the premier modifiable risk factor for stroke.1,2 Indeed, ≤50% of strokes may be attributable to hypertension, and the relationship of hypertension with stroke also comprises distinct independent links between both systolic and diastolic hypertension and the occurrence of both primary and recurrent strokes.3 Furthermore, the underlying pathophysiological rationale and clinical trial evidence for lowering blood pressure (BP) in people with hypertension to safely prevent a primary stroke of any type are overwhelmingly clear.4 However, when it comes to recurrent stroke prevention, questions surrounding BP treatment linger, including what exactly to do, when precisely to do it, and whether the approach should vary by type of patient. This comparative lack of clarity about the nature of the BP-lowering strategy after a stroke has arisen because of theoretical efficacy/safety concerns related to the acuity and type of index stroke, as well as the paucity of published hypertension treatment trials for recurrent stroke prevention.5,6 As such, expert consensus recommendations for BP lowering to avert vascular events either do not specifically or adequately address recurrent stroke prevention (Eighth Joint National Committee,7 American Heart Association guidelines for managing BP in coronary artery disease)8 or are largely based on a paucity of clinical trials or reviews that did not specifically address key issues of acuity, stroke type, or BP-lowering intensity.9 Nonetheless, some expert opinion suggests that management of high vascular risk patients with hypertension remains aggressive for now until specific compelling trial evidence is available.10The importance of optimizing recurrent stroke prevention to lessen the personal and societal burden of stroke cannot be overemphasized. Approximately 25% of stroke cases are recurrent events, often occurring within the first year of a prior stroke or transient ischemic attack (TIA),11 and the case mortality …