Intensive blood pressure management reduces risk of recurrent stroke

1. In this randomized control trial conducted in Japan, intensive blood pressure control (less than 130/80) was associated with reduced risk of first recurrent stroke.

2. While the target blood pressure was 120/80, average blood pressure actually achieved in the intensive group was 127/78

Evidence Rating Level: 1 (Excellent)

Study Rundown: Strokes are responsible for a significant amount of morbidity and mortality worldwide, and high blood pressure is a clearly established risk factor. While the Systolic Blood Pressure Intervention Trial (SPRINT) showed tighter blood pressure control led to improved outcomes, patients with a prior stroke were excluded. This trial was conducted to answer that question.

In this randomized control trial with 1263 patients in Japan, intensive blood pressure reduction targeting <120/80 (but achieving < 130/80) was associated with reduced risk of recurrent stroke. There was no increase in adverse events in the intensive group, including hypotension related events like syncope or dizziness. The benefit was driven largely by reduction in hemorrhagic stroke.

Click to read the study in JAMA Neurology

Relevant Reading: Achieved systolic blood pressure in older people: a systematic review and meta-analysis

In-Depth [randomized controlled trial]: This was a prospective, multi-center, open, masked en point, randomized control trial conducted in Japan including 1263 patients with prior history of stroke. Participants were randomized to intensive blood pressure lowering (target < 120/80) or standard (target < 140/90). The study ran between October 2010 and December 2016. Inclusion criteria included stroke in the past 3 years, age 50-85, independent ambulation, and systolic blood pressure of 130-180 mmHg or diastolic blood pressure 80 – 110 mmHg on 0-3 antihypertensives. Average age was 67.2 and 69.4% of patients were male. Mean follow up was 3.9 years. Mean starting blood pressure was 145.4/83.6 mmHg.

The primary outcome was recurrent stroke (ischemic or hemorrhagic). Throughout follow up mean blood pressure in the standard group was 133.2/77.7 mmHg and 126.7/74.4 mmHg in the intensive group. Mean antihypertensives used was 1.6 in standard group and 2.8 in intensive group. During follow up there were 91 first recurrent strokes (79 ischemic, 12 hemorrhagic). Annualized recurrent stroke rate was 2.26% in the standard group compared with 1.65% in the intensive group (HR 0.73, 95% CI 0.49-1.11, p=0.15). This was driven largely by reduction in hemorrhagic stroke rate (0.46% vs 0.04%, HR 0.09, 95% CI 0.01-0.70, p=0.02). There was no increase in adverse events in the intensive group, including hypotension related events like syncope or dizziness. When the results were combined with 3 other randomized controlled trials in a meta-analysis, they found benefit with intensive blood pressure control (RR 0.78, 95% CI 0.64-0.96, p=0.02). Number needed to treat was was 67.

Image: PD

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