Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6105 individuals with previous stroke or transient ischaemic attack Comparative effectiveness of home blood pressure telemonitoring (HBPTM) plus nurse case management versus HBPTM alone among Black and Hispanic stroke survivors: study protocol for a randomized controlled trial Does telephone follow-up improve blood pressure after minor stroke or TIA? The preventing recurrent vascular events and neurological worsening through intensive organized case-management (PREVENTION) trial protocol [clinicaltrials.gov identifier: NCT00931788] Lower target blood pressures are safe and effective for the prevention of recurrent stroke: the PROGRESS trial 2015 guidelines of the Taiwan Society of Cardiology and the Taiwan Hypertension Society for the management of hypertension. Blood pressure 1 year after stroke: the need to optimize secondary prevention. Hypertensive eye ground changes. Prevalence, relation to blood pressure and prognostic importance. The study of men born in 1913. Effects of individual risk factors on the incidence of cardiovascular events in the treated hypertensive patients of the Hypertension Optimal Treatment Study. HOT Study Group. Factors Affecting Changes in Blood Pressure After Acute Stroke The Japanese Trial to Assess Optimal Systolic Blood Pressure in Elderly Hypertensive Patients (JATOS): Protocol, Patient Characteristics, and Blood Pressure during the First 12 Months Use of ramipril in preventing stroke: double blind randomised trial Blood pressure and LDL-cholesterol targets for prevention of recurrent strokes and cognitive decline in the hypertensive patient: design of the European Society of Hypertension-Chinese Hypertension League Stroke in Hypertension Optimal Treatment randomized trial. Risk factors for non-haemorrhagic stroke in patients with coronary heart disease and the effect of lipid-modifying therapy with pravastatin Long-term prognostic implications of visit-to-visit blood pressure variability in patients with ischemic stroke.
BACKGROUND Blood pressure is a determinant of the risk of stroke among both hypertensive and non-hypertensive individuals with cerebrovascular disease . However , there is uncertainty about the efficacy and safety of blood-pressure-lowering treatments for many such patients . The perindopril protection against recurrent stroke study ( PROGRESS ) was design ed to determine the effects of a blood-pressure-lowering regimen in hypertensive and non-hypertensive patients with a history of stroke or transient ischaemic attack . METHODS 6105 individuals from 172 centres in Asia , Australasia , and Europe were r and omly assigned active treatment ( n=3051 ) or placebo ( n=3054 ) . Active treatment comprised a flexible regimen based on the angiotensin- converting-enzyme inhibitor perindopril ( 4 mg daily ) , with the addition of the diuretic indapamide at the discretion of treating physicians . The primary outcome was total stroke ( fatal or non-fatal ) . Analysis was by intention to treat . FINDINGS Over 4 years of follow up , active treatment reduced blood pressure by 9/4 mm Hg . 307 ( 10 % ) individuals assigned active treatment suffered a stroke , compared with 420 ( 14 % ) assigned placebo ( relative risk reduction 28 % [ 95 % CI 17 - 38 ] , p<0.0001 ) . Active treatment also reduced the risk of total major vascular events ( 26 % [ 16 - 34 ] ) . There were similar reductions in the risk of stroke in hypertensive and non-hypertensive subgroups ( all p<0.01 ) . Combination therapy with perindopril plus indapamide reduced blood pressure by 12/5 mm Hg and stroke risk by 43 % ( 30 - 54 ) . Single-drug therapy reduced blood pressure by 5/3 mm Hg and produced no discernable reduction in the risk of stroke . INTERPRETATION This blood-pressure-lowering regimen reduced the risk of stroke among both hypertensive and non-hypertensive individuals with a history of stroke or transient ischaemic attack . Combination therapy with perindopril and indapamide produced larger blood pressure reductions and larger risk reductions than did single drug therapy with perindopril alone . Treatment with these two agents should now be considered routinely for patients with a history of stroke or transient ischaemic attack , irrespective of their blood pressure Background Black and Hispanic stroke survivors experience higher rates of recurrent stroke than whites . This disparity is partly explained by disproportionately higher rates of uncontrolled hypertension in these population s. Home blood pressure telemonitoring ( HBPTM ) and nurse case management ( NCM ) have proven efficacy in addressing the multilevel barriers to blood pressure ( BP ) control and reducing BP . However , the effectiveness of these interventions has not been evaluated in stroke patients . This study is design ed to evaluate the comparative effectiveness , cost-effectiveness and sustainability of these two telehealth interventions in reducing BP and recurrent stroke among high-risk Black and Hispanic stroke survivors with uncontrolled hypertension . Methods / Design A total of 450 Black and Hispanic patients with recent nondisabling stroke and uncontrolled hypertension are r and omly assigned to one of two 12-month interventions : 1 ) HBPTM with wireless feedback to primary care providers or 2 ) HBPTM plus individualized , culturally-tailored , telephone-based NCM .  Patients are recruited from stroke centers and primary care practice s within the Health and Hospital Corporations ( HHC ) Network in New York City . Study visits occur at baseline , 6 , 12 and 24 months . The primary outcomes are within-patient change in systolic BP at 12 months , and the rate of stroke recurrence at 24 months . The secondary outcome is the comparative cost-effectiveness of the interventions at 12 and 24 months ; and exploratory outcomes include changes in stroke risk factors , health behaviors and treatment intensification . Recruitment for the stroke telemonitoring hypertension trial is currently ongoing . Discussion The combination of two established and effective interventions along with the utilization of health information technology supports the sustainability of the HBPTM + NCM intervention and feasibility of its widespread implementation . Results of this trial will provide strong empirical evidence to inform clinical guidelines for management of stroke in minority stroke survivors with uncontrolled hypertension . If effective among Black and Hispanic stroke survivors , these interventions have the potential to substantially mitigate racial and ethnic disparities in stroke recurrence . Trial registration Clinical Trials.gov NCT02011685 . Registered 10 December 2013 BACKGROUND hypertension is a common risk factor for stroke/transient ischaemic attack ( TIA ) and there is good evidence that blood pressure ( BP ) control prevents recurrent stroke . We investigated whether telephone follow-up ( TFU ) improved risk factor management in hypertensive patients after stroke/TIA . METHODS we conducted a r and omised controlled trial and assigned hypertensive patients within 1 month of stroke or TIA to receive usual care ( n = 27 ) or usual care plus regular TFU ( n = 29 ) . Primary outcome was the difference in 12 h ambulatory systolic BP change from baseline to 6 months ( DeltaSBP ) in both groups . TFU at 7 days , 1 , 2 and 4 months included patient-focussed education and goal setting . RESULTS mean baseline BP was 145/83 mm Hg ( st and ard deviation ( SD ) 21/14 ) . There was no significant difference in DeltaSBP over 6 months with TFU . Median DeltaSBP was 0 mm Hg ( interquartile range 19.5 ) in the TFU group and 3.0 mm Hg ( 20 ) fall in the usual care group ( P = 0.29 ) . Post hoc analysis showed that statin use increased from baseline to 6 months ( P = 0.02 ) and cholesterol was significantly lower at 6 months in all patients ( mean reduction 0.95 mmol/l ; P < 0.001 ) . CONCLUSION our study found TFU that promoted patient-led management of risk factors did not improve BP control over 6-month follow-up in primary care after stroke/TIA Background Survivors of transient ischemic attack ( TIA ) or stroke are at high risk for recurrent vascular events and aggressive treatment of vascular risk factors can reduce this risk . However , vascular risk factors , especially hypertension and high cholesterol , are not managed optimally even in those patients seen in specialized clinics . This gap between the evidence for secondary prevention of stroke and the clinical reality leads to suboptimal patient outcomes . In this study , we will be testing a pharmacist case manager for delivery of stroke prevention services . We hypothesize this new structure will improve processes of care which in turn should lead to improved outcomes . Methods We will conduct a prospect i ve , r and omized , controlled open-label with blinded ascertainment of outcomes ( PROBE ) trial . Treatment allocation will be concealed from the study personnel , and all outcomes will be collected in an independent and blinded manner by observers who have not been involved in the patient 's clinical care or trial participation and who are masked to baseline measurements . Patients will be  r and omized to control or a pharmacist case manager treating vascular risk factors to guideline -recommended target levels . Eligible patients will include all adult patients seen at stroke prevention clinics in Edmonton , Alberta after an ischemic stroke or TIA who have uncontrolled hypertension ( defined as systolic blood pressure ( BP ) > 140 mm Hg ) or dyslipidemia ( fasting LDL-cholesterol > 2.00 mmol/L ) and who are not cognitively impaired or institutionalized . The primary outcome will be the proportion of subjects who attain ' optimal BP and lipid control'(defined as systolic BP < 140 mm Hg and fasting LDL cholesterol < 2.0 mmol/L ) at six months compared to baseline ; 12-month data will also be collected for analyses of sustainability of any effects . A variety of secondary outcomes related to vascular risk and health-related quality of life will also be collected . Conclusions Nearly one-quarter of those who survive a TIA or minor stroke suffer another vascular event within a year . If our intervention improves the provision of secondary prevention therapies in these patients , the clinical ( and financial ) implication s will be enormous Objective To explore the likely optimum blood pressure ( BP ) level for patients with a history of cerebrovascular disease . Methods The Perindopril Protection Against Recurrent Stroke Study ( PROGRESS ) was a r and omized , placebo-controlled trial that established the beneficial effects of BP lowering in 6105 patients with cerebrovascular disease . The present study comprises two series of post hoc analyses . The first was design ed to investigate the effects of r and omized treatment on recurrent stroke by baseline BP levels , and the second was a corresponding observational analysis investigating the association between achieved follow-up BP levels and recurrent stroke risk . Results Analyses of the r and omized treatment comparisons showed that BP lowering with combination therapy produced similar risk reductions in each of four subgroups defined by baseline BP of less than 120 , 120–139 , 140–159 , and 160 mmHg or greater ( P homogeneity = 0.5 ) . The effects of single-drug therapy were also comparable across these subgroups ( P homogeneity = 0.2 ) , but consistently greater benefits were observed with combination compared to single-drug therapy . The analyses of achieved follow-up BP showed that the lowest risk of recurrence was among the one-quarter of participants with the lowest follow-up BP levels ( median 112/72 mmHg ) , and that risks rose progressively with higher follow-up BP levels . Minor side-effects were progressively more common at lower BP levels ( P homogeneity = 0.04 ) , but there was no excess of serious complications ( all P homogeneity > 0.2 ) . Conclusion These analyses provide no evidence of a J-curve relationship between BP level and stroke risk among patients with cerebrovascular disease , and identify no patient group among whom more intensive BP lowering would not be expected to produce greater risk reductions It has been almost 5 years since the publication of the 2010 hypertension guidelines of the Taiwan Society of Cardiology ( TSOC ) . There is new evidence regarding the management of hypertension , including r and omized controlled trials , non-r and omized trials , post-hoc analyses , subgroup analyses , retrospective studies , cohort studies , and registries . More recently , the European Society of Hypertension ( ESH ) and the European Society of Cardiology ( ESC ) published joint hypertension guidelines in 2013 . The panel members who were appointed to the Eighth Joint National Committee ( JNC ) also published the 2014 JNC report . Blood pressure ( BP ) targets have been changed ; in particular , such targets have been loosened in high risk patients . The Executive Board members of TSOC and the Taiwan Hypertension Society ( THS ) aim ed to review up date d information about the management of hypertension to publish an up date d hypertension guideline in Taiwan . We recognized that hypertension is the most important risk factor for global disease burden . Management of hypertension is especially important in Asia where the prevalence rate grows faster than other parts of the world . In most countries in East Asia , stroke surpassed coronary heart disease ( CHD ) in causing premature death . A diagnostic algorithm was proposed , emphasizing the importance of home BP monitoring  and ambulatory BP monitoring  for better detection of night time hypertension , early morning hypertension , white-coat hypertension , and masked hypertension . We disagreed with the ESH/ESH joint hypertension guidelines suggestion to loosen BP targets to < 140/90 mmHg for all patients . We strongly disagree with the suggestion by the 2014 JNC report to raise the BP target to < 150/90 mmHg for patients between 60 - 80 years of age . For patients with diabetes , CHD , chronic kidney disease who have proteinuria , and those who are receiving antithrombotic therapy for stroke prevention , we propose BP targets of < 130/80 mmHg in our guidelines . BP targets are < 140/90 mmHg for all other patient groups , except for patients ≥80 years of age in whom a BP target of < 150/90 mmHg would be optimal . For the management of hypertension , we proposed a treatment algorithm , starting with life style modification ( LSM ) including S-ABCDE ( Sodium restriction , Alcohol limitation , Body weight reduction , Cigarette smoke cessation , Diet adaptation , and Exercise adoption ) . We emphasized a low-salt strategy instead of a no-salt strategy , and that excessively aggressive sodium restriction to < 2.0 gram/day may be harmful . When drug therapy is considered , a strategy called " PROCEED " was suggested ( Previous experience , Risk factors , Organ damage , Contraindications or unfavorable conditions , Expert 's or doctor 's judgment , Expenses or cost , and Delivery and compliance issue ) . To predict drug effects in lowering BP , we proposed the " Rule of 10 " and " Rule of 5 " . With a st and ard dose of any one of the 5 major classes of anti-hypertensive agents , one can anticipate approximately a 10-mmHg decrease in systolic BP ( SBP ) ( Rule of 10 ) and a 5-mmHg decrease in diastolic BP ( DBP ) ( Rule of 5 ) . When doses of the same drug are doubled , there is only a 2-mmHg incremental decrease in SBP and a 1-mmHg incremental decrease in DBP . Preferably , when 2 drugs with different mechanisms are to be taken together , the decrease in BP is the sum of the decrease of the individual agents ( approximately 20 mmHg in SBP and 10 mmHg in DBP ) . Early combination therapy , especially single-pill combination ( SPC ) , is recommended . When patient 's initial treatment can not get BP to targeted goals , we have proposed an adjustment algorithm , " AT GOALs " ( Adherence , Timing of administration , Greater doses , Other classes of drugs , Alternative combination or SPC , and LSM + Laboratory tests ) . Treatment of hypertension in special conditions , including treatment of resistant hypertension , hypertension in women , and perioperative management of hypertension , were also mentioned . The TSOC/THS hypertension guidelines provide the most up date d information available in the management of hypertension . The guidelines are not m and atory , and members of the task force fully realize that treatment of hypertension should be individualized to address each patient 's circumstances . Ultimately , the decision of the physician decision remains of the utmost importance in hypertension management Lowering blood pressure ( BP ) in stroke survivors reduces the risk of recurrent stroke . We tested the hypothesis that a nurse-led nonpharmacologic intervention would lower the BP of participants in an intervention group compared with a control group . A total of 349 patients who had sustained acute stroke or transient ischemic attack were r and omly assigned to either usual care or to 4 home visits by a nurse . During the visits , the nurse measured and recorded BP and provided individually tailored counseling on a healthy lifestyle . A total of 303 patients completed the 1-year follow up . No change in systolic BP was noted in either the intervention group or the control group . Because of an increase in diastolic BP in the control group ( P = .03 ) , a difference in mean diastolic BP between the 2 groups was found at follow-up ( P = .007 ) . Mean BP at follow-up was 139/82 mm Hg in the intervention group and 142/86 mm Hg in the control group . Linear regression analysis demonstrated that BP at the point of discharge was the strongest predictor of BP 1 year later ( P < .0001 ) . The proportion of patients on antihypertensive medication increased in the intervention group ( P = .002 ) . Patients were compliant with antihypertensive therapy , and 92 % of the hypertensive patients in the intervention group followed the advice to see a general practitioner ( GP ) for BP checkups . At follow-up , 187 patients ( 62 % ) were hypertensive , with no difference in the rate of hypertension seen between the groups . Our data indicate that home visits by nurses did not result in a lowering of BP . Patients complied with antihypertensive therapy and GP visits in the case of hypertension . Nonetheless , the majority of patients were hypertensive at the 1-year follow up ABSTRACT . As part of a prospect i ve population study of cardiovascular disease , ophthalmoscopic examination was performed in 855 r and omly selected 50-year-old men in 1963 . The examination was repeated four years later , in 1967 . On both occasions haemorrhages , exu date s and papillary aedema were rarely seen . Attenuating arterioles , focal narrowing , crossing phenomena and broadened light reflex were all related to BP but attenuating arterioles and /or focal narrowing discriminated BP best . Isolated broadened reflex and /or crossing phenomena were not related to BP . The change in BP over four and ten years was the same in those who had and those who did not have hypertensive eye ground changes at the initial examination , indicating that eye ground changes do not precede hypertension . Mortality data and the morbidity in myocardial infa rct ion and stroke were followed up until 1975 . The importance of the separate eye ground variables for these mortality and morbidity end-points was analyzed , taking into account the importance of BP , serum cholesterol and smoking . Focal narrowings were of importance for mortality , regardless of its cause , for stroke and for death from malignancy . Crossing phenomena were of importance for mortality , regardless of cause , for fatal coronary heert disease , for stroke and for deaths other than cardiovascular and cancer deaths . The eye ground variables are thus of differing importance for different end-points . Grouping them as in Keith and Wagener 's or other classification systems , means a loss of information and should be avoided BACKGROUND The Hypertension Optimal Treatment ( HOT ) Study has provided information about cardiovascular events in 18790 hypertensives , subjected to pronounced blood pressure ( BP ) lowering for a mean of 3.8 years . The HOT study data have subsequently been analysed after stratification of the patients according to global cardiovascular risk , and it has been found that , despite intensive blood pressure lowering in all risk strata , morbid event rates increased with increasing risk stratum . OBJECTIVES Previously analysed global risk strata were based on combinations of risk factors . The analyses presented here were intended to provide information on the relative role that the presence of each individual factor may have in increasing cardiovascular risk , despite good BP control . METHODS Risk ratios ( RR ) for patients with and those without a risk factor were calculated with 95 % confidence intervals ( CI ) using a Cox proportional hazard model , and adjusted for all variables except the one under examination . RESULTS For all risk factors considered and for all types of event , RR were always greater than 1 , indicating a greater risk in the presence , compared with that in the absence of each factor . The male gender was a statistically significant risk for cardiovascular ( CV ) events , CV and total mortality and particularly for myocardial infa rct ion ( MI ) ; age > or = 65 years for CV events , stroke , CV and particularly total mortality ; smoking for all events analysed , but particularly for total mortality ( twice higher in smokers than in non-smokers ) ; high serum cholesterol ( > 6.8 mmol/l ) for CV events , MI and CV mortality ; high serum creatinine ( > 155 micromol/l ) for CV events , stroke , CV and total mortality ; diabetes for CV events , stroke , total mortality and particularly CV mortality ; and ischaemic heart disease for all events analysed . Adjusted RR were often close to or greater than 2 . CONCLUSIONS Each of the risk factors considered was found to be an important cause of residual risk , despite good BP control . These findings emphasize the importance of addressing other correctable risk factors , e.g. smoking , hypercholesterolaemia and diabetes , as well as rigorous control of blood pressure , and of initiating antihypertensive therapy before cardiovascular and renal damage becomes manifest We sought to establish the pattern of blood pressure ( BP ) change after hospitalization for acute hemispheric stroke . Methods In 292 patients from the Leicester teaching hospitals with acute hemispheric stroke within the previous 24 hours ( 139 men ; median age , 75 years [ range , 42 to 98 years ] ) , we prospect ively studied BP changes between admission , 24 hours , 1 week , and 4 to 6 weeks . Changes were assessed in relation to the main stroke risk factors , stroke type and severity , and antihypertensive drug treatment . All subjects were followed up for 1 week , with 117 subjects followed up for 4 to 6 weeks . Changes were assessed by repeated- measures ANOVA , and Student 's t tests were used to compare group pairs . Results Systolic and diastolic BP fell by 12 mm Hg ( 95 % confidence interval [ CI ] , 8 to 15 mm Hg ) and 7 mm Hg ( 95 % CI , 5 to 9 mm Hg ) , respectively , in the first 24 hours and 22 mm Hg ( 95 % CI , 18 to 25 mm Hg ) and 12 mm Hg ( 95 % CI , 10 to 14 mm Hg ) , respectively , during the first week ( all changes significant at P<.01 ) but no further thereafter . In those patients receiving no antihypertensive medication before or after stroke , the pattern of change was similar to that of the whole group . Previously diagnosed hypertensive subjects ( n=106 ) had higher initial BP values than did normotensive subjects , although by 1 week the levels were not significantly different . Patients with cerebral hemorrhage confirmed by computed tomography ( n=20 ) had higher systolic BP , but not diastolic BP , throughout the first week than those with cerebral infa rct ion ( n=89 ) . The severity of stroke , age , and previous stroke history did not appear to alter the BP pattern . Stroke patients who were moderate to heavy alcohol consumers had lower convalescent systolic BP levels than lighter drinkers or abstainers . Conclusions We have demonstrated a marked fall in systolic and diastolic BP levels during the first 7 days after acute hemispheric stroke , with little change thereafter . Higher initial systolic BP values were found in patients with cerebral hemorrhage compared with those with cerebral infa rct . Moderate to heavy alcohol consumption before stroke was associated with a greater systolic BP decline in the first week after the event compared with stroke patients who were light drinkers or abstainers The benefits of a systolic blood pressure ( BP ) below 150–160 mmHg are well established ; whether a systolic BP of less than 140 mmHg provides additional benefits remains controversial . This study was design ed to compare the 2-year effect of a strict treatment to maintain systolic BP below 140 mmHg ( group A ) and that of a mild treatment to maintain systolic BP at between 140 and below 160 mmHg ( group B ) . The study design followed the Prospect i ve R and omized Open Blinded End-point ( PROBE ) study . The subjects were elderly patients ( 65–85 years old ) who consistently had a systolic BP of 160 mmHg or higher . The baseline drug was efonidipine hydrochloride ( efonidipine ) , a long-acting dihydropiridine calcium antagonist . The primary endpoints were stroke , cardiac disease , vascular disease , and renal failure . After a run-in period of 2 to 4 weeks , 2,165 patients were assigned to group A and 2,155 patients to group B. There were no significant differences between the groups in sex , age , baseline BP , or other cardiovascular risk factors . The systolic BP was 7.2 mmHg lower ( p<0.0001 ) and the diastolic BP 2.4 mmHg lower ( p<0.0001 ) in group A than in group B after 12 months of treatment . As of this interim analysis , primary endpoints have occurred in 87 patients ( stroke in 58 patients , cardiac disease in 27 patients , occlusive arterial disease in 1 patient , and renal failure in 1 patient ) . Five patients have died of stroke and 2 patients of myocardial infa rct ion . The primary -endpoint-related morbidity rate was 20.9/1,000 patient-years , and the mortality rate was 1.7/1,000 patient-years . Currently available results indicate that this study , one of the largest r and omized trials of antihypertensive therapy in elderly patients in Japan , was conducted safely . The final results are expected to provide important and practical information for the management of hypertension in elderly patients Abstract Objective : To determine the effect of the angiotensin converting enzyme inhibitor ramipril on the secondary prevention of stroke . Design : R and omised controlled trial with 2 × 2 factorial design . Setting : 267 hospitals in 19 countries . Participants : 9297 patients with vascular disease or diabetes plus an additional risk factor , followed for 4.5 years as part of the HOPE study . Outcome measures : Stroke ( confirmed by computed tomography or magnetic resonance imaging when available ) , transient ischaemic attack , and cognitive function . Blood pressure was recorded at entry to the study , after 2 years , and at the end of the study . Results : Reduction in blood pressure was modest ( 3.8 mm Hg systolic and 2.8 mm Hg diastolic ) . The relative risk of any stroke was reduced by 32 % ( 156 v 226 ) in the ramipril group compared with the placebo group , and the relative risk of fatal stroke was reduced by 61 % ( 17 v 44 ) . Benefits were consistent across baseline blood pressures , drugs used , and subgroups defined by the presence or absence of previous stroke , coronary artery disease , peripheral arterial disease , diabetes , or hypertension . Significantly fewer patients on ramipril  had cognitive or functional impairment . Conclusion : Ramipril  reduces the incidence of stroke in patients at high risk , despite a modest reduction in blood pressure . What is already known on this topic Treatment with aspirin and lowering blood pressure reduce the incidence of stroke What this study adds Ramipril , an angiotensin converting enzyme inhibitor , reduces strokes in patients at high risk whose blood pressure is not elevated , despite only a modest lowering of blood pressure The benefits are observed even when patients receive aspirin and other blood pressure lowering BACKGROUND AND OBJECTIVES The SBP values to be achieved by antihypertensive therapy in order to maximize reduction of cardiovascular outcomes are unknown ; neither is it clear whether in patients with a previous cardiovascular event , the optimal values are lower than in the low-to-moderate risk hypertensive patients , or a more cautious blood pressure ( BP ) reduction should be obtained . Because of the uncertainty whether ' the lower the better ' or the ' J-curve ' hypothesis is correct , the European Society of Hypertension and the Chinese Hypertension League have promoted a r and omized trial comparing antihypertensive treatment strategies aim ing at three different SBP targets in hypertensive patients with a recent stroke or transient ischaemic attack . As the optimal level of low-density lipoprotein cholesterol ( LDL-C ) level is also unknown in these patients , LDL-C-lowering has been included in the design . PROTOCOL DESIGN The European Society of Hypertension-Chinese Hypertension League Stroke in Hypertension Optimal Treatment trial is a prospect i ve multinational , r and omized trial with a 3 × 2 factorial design comparing : three different SBP targets ( 1 , < 145 - 135 ; 2 , < 135 - 125 ; 3 , < 125 mmHg ) ; two different LDL-C targets ( target A , 2.8 - 1.8 ; target B , < 1.8 mmol/l ) . The trial is to be conducted on 7500 patients aged at least 65 years ( 2500 in Europe , 5000 in China ) with hypertension and a stroke or transient ischaemic attack 1 - 6 months before r and omization .  Antihypertensive and statin treatments will be initiated or modified using suitable registered agents chosen by the investigators , in order to maintain patients within the r and omized SBP and LDL-C windows . All patients will be followed up every 3 months for BP and every 6 months for LDL-C. Ambulatory BP will be measured yearly . OUTCOMES Primary outcome is time to stroke ( fatal and non-fatal ) . Important secondary outcomes are : time to first major cardiovascular event ; cognitive decline ( Montreal Cognitive Assessment ) and dementia . All major outcomes will be adjudicated by committees blind to r and omized allocation . A Data and Safety Monitoring Board has open access to data and can recommend trial interruption for safety . SAMPLE SIZE CALCULATION It has been calculated that 925 patients would reach the primary outcome after a mean 4-year follow-up , and this should provide at least 80 % power to detect a 25 % stroke difference between SBP targets and a 20 % difference between LDL-C targets Objective To determine the relative importance of recognised risk factors for non-haemorrhagic stroke , including serum cholesterol and the effect of  cholesterol-lowering therapy  , on the occurrence of non-haemorrhagic stroke in patients enrolled in the LIPID ( Long-term Intervention with Pravastatin in Ischaemic Disease ) study . Design The LIPID study was a placebo-controlled , double-blind trial of the efficacy on coronary heart disease mortality of pravastatin therapy over 6 years in 9014 patients with previous acute coronary syndromes and baseline total cholesterol of 4–7 mmol/l . Following identification of patients who had suffered non-haemorrhagic stroke , a pre-specified secondary end point , multivariate Cox regression was used to determine risk in the total population . Time-to-event analysis was used to determine the effect of pravastatin therapy on the rate of non-haemorrhagic stroke . Results There were 388 non-haemorrhagic strokes in 350 patients . Factors conferring risk of future non-haemorrhagic stroke were age , atrial fibrillation , prior stroke , diabetes , hypertension , systolic blood pressure , cigarette smoking , body mass index , male sex and creatinine clearance . Baseline lipids did not predict non-haemorrhagic stroke . Treatment with pravastatin  reduced non-haemorrhagic stroke by 23 % ( P = 0.016 ) when considered alone , and 21 % ( P = 0.024 ) after adjustment for other risk factors . Conclusions The study confirmed the variety of risk factors for non-haemorrhagic stroke . From the risk predictors , a simple prognostic index was created for non-haemorrhagic stroke to identify a group of patients at high risk . Treatment with pravastatin result ed in significant additional benefit after allowance for risk factors BACKGROUND Blood pressure ( BP ) variability ( BPV ) is a novel risk factor for the development of atherosclerotic diseases . High BPV has recently been shown to predict all-cause and cardiovascular mortality in patients with lacunar infa rct . Whether BPV has prognostic implication s in patients with ischemic stroke subtypes , other than those due to small-vessel occlusion , remains uncertain . METHODS We prospect ively followed up the clinical outcome of 632 consecutive ischemic stroke patients without atrial fibrillation . The average BP and BPV , as determined by the coefficient of variation of the systolic and diastolic BP , were recorded during a mean 12 ± 6 outpatient clinic visits . RESULTS The average age of the population was 71 ± 11 years . After a mean of 76 ± 18 months of follow-up , 161 patients died ( 26 % ) ; 35 % ( n = 56 of 161 ) of these deaths were due to cardiovascular causes . Sixteen percent and 5 % developed recurrent stroke and acute coronary syndrome ( ACS ) , respectively . After adjusting for mean systolic BP and confounding variables , patients with high systolic BPV were at significantly greater risk of cardiovascular mortality ( hazards ratio ( HR ) = 2.36 ; 95 % confidence interval ( CI ) = 1.02 - 5.49 ; P < 0.05 ) . High systolic BPV also predicted all-cause mortality after adjusting for mean systolic BP ( HR = 1.79 ; 95 % CI = 1.16 - 2.75 ; P < 0.05 ) . There was no association between systolic BPV and nonfatal recurrent stroke or nonfatal ACS . Raised diastolic BPV did not predict recurrent nonfatal stroke , nonfatal ACS , or mortality . CONCLUSIONS Visit-to-visit systolic BPV predicts long-term all-cause and cardiovascular mortality in patients with ischemic stroke without atrial fibrillation , independent of other conventional risk factors , including average BP control
Evidence from RCTs supports the use of diuretics-based treatment , especially when combined with ACEI , for the secondary prevention of recurrent stroke and any vascular events in patients who have suffered from stroke
Abstract Hypertension is the most important risk factor for stroke and stroke recurrence .
However , the preferred blood pressure (BP)-lowering drug class for patients who have suffered from a stroke has yet to be determined .