What Is the Appropriate Target Blood Pressure inPatients With ICH?

Immediately after an ICH, it is perhaps more appropriate to tailor the target

BP to each patient rather than using a “one size fits all” approach.

The possibility of increased ICP and a history of chronic untreated

hypertension should be considered while choosing the target.

How Fast Should Blood Pressure Be Lowered?

Results of small studies suggest that rapidly lowering MAP by

approximately 15% does not lower cerebral blood flow, whereas reductions

of 20% can do so.

Therefore, if BP-lowering is considered, current guidelines suggest

cautious lowering of BP by no more that 20% in the first 24 hours.

Should Blood Pressure Be Elevated to Improve CerebralPerfusion in Patients With Ischemic Stroke?

Answer: A few small case series have shown neurological improvement with

induced hypertensive therapy.

Studies are underway to assess the usefulness of this form of therapy in

patients with a diffusion–perfusion mismatch on MRI.

In the meantime, it is reasonable to try volume expansion and/or

vasopressors in patients with hypotensive stroke or in patients who have

had a worsening of the neurological deficit in association with a drop in BP.

Should Patients on Antihypertensive Agents Have TheirMedications Held or Continued?

There are no substantial clinical data available to answer this question and a

clinical trial is underway to address this issue (Continue or stop poststroke

antihypertensives study).

The AHA/ASA guidelines recommend restarting antihypertensives at 24

hours in previously hypertensive neurologically stable patients unless

contraindicated

PROGRESS trial

The PROGRESS trial included over 6100 patients (mean age 64 years) with an ischemic or, less often, hemorrhagic stroke or transient ischemic attack within the previous five years (median eight months)

The patients were randomly assigned to perindopril or placebo; the diuretic indapamide was added as necessary in the perindopril group.

The mean baseline blood pressure was 147/86 mmHg; approximately one half of patients were hypertensive (mean 159/94 mmHg), while remaining patients had highnormal values (mean 136/79 mmHg).

A reduction in blood pressure of 9/4 mmHg in the perindopril group

compared with placebo decreased the rate of the primary end point of fatal

or nonfatal stroke

The stroke prevention benefit was related to the degree of blood pressure

reduction, being most prominent (relative risk reduction 43 percent) and

statistically significant in patients treated with combination therapy

(perindopril plus indapamide) who had a 12/5 mmHg mean reduction in

blood pressure compared with placebo

PROGRESS trial

The reduction in recurrent stroke with antihypertensive therapy was seen in

both hypertensive (11.1 versus 16.2 percent, relative risk reduction 32

percent) and nonhypertensive patients (9.1 versus 11.5 percent, relative risk

reduction 21 percent).

Thus, both the risk of stroke and the absolute benefit from antihypertensive

therapy were greater in the hypertensive patients. Similar findings were

noted when all major vascular events were evaluated.

PROGRESS trial

PRoFESS trial

The PRoFESS trial (Prevention Regimen for Effectively Avoiding Second

Strokes) randomly assigned 20,332 patients with non cardioembolic ischemic

stroke to receive either fixed dose telmisartan (80 mg daily) or placebo.

All other antihypertensive drugs, except for angiotensin receptor blockers,

were permitted as add on therapy.

Approximately three quarters of patients had a prior history of hypertension,

and the average blood pressure was 144/84 mmHg in both groups at baseline.

At an average followup of 2.5 years,

There was no significant difference between the telmisartan and placebo groups in

the primary outcome of recurrent stroke (8.7 versus 9.2 percent, hazard ratio [HR]

0.95, 95% CI 0.861.04),

or in secondary outcomes including major cardiovascular events (13.5 versus 14.4

percent, HR 0.94, 95% CI 0.871.01).

Significant benefit compared with placebo would not have been expected since

telmisartan therapy only reduced the blood pressure by an average 3.8/2.0 mmHg

more than placebo.

PRoFESS trial

PATS trialThe PATS trial (Poststroke Antihypertensive Treatment Study) randomly assigned 5665 Chinese patients with a history of stroke (mostly ischemic) or TIA to treatment with indapamide (2.5 mg daily) or placebo .

The average interval from stroke to randomization was 31 months, and the average blood pressure at randomization was 154/93 mmHg.

At a median followup of two years, active treatment reduced blood pressure by a mean of 6.8/3.3 mmHg.

There were significantly fewer strokes in the active treatment compared with the placebo group (143 versus 219, hazard ratio [HR] 0.69, 95% CI 0.54–0.89).

Meta- analysis

A metaanalysis of eight placebo controlled trials of angiotensin inhibition included almost 30,000 patients, most of whom came from the PRoFESS trial .

Antihypertensive therapy (most of the included trials in this metaanalysis compared angiotensin inhibitors with placebo) resulted in a significant reduction in major cardiovascular events (13.1 versus 14.7 percent, risk ratio 0.92, 95% CI 0.860.98) and an almost significant reduction in recurrent stroke (9.0 versus 9.6 percent, risk ratio 0.94, 95% CI 0.871.01).

Meta- analysis

The second metaanalysis was published in 2011 and included 40,300

patients from 16 randomized trials of antihypertensive therapy in patients

with a prior stroke, approximately one half of whom came from PRoFESS .

Antihypertensive therapy was associated with a significant reduction in

recurrent stroke (relative risk 0.81, 95% CI 0.730.91).

A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

Introduction

Treatment of hypertension is possibly the most important intervention for

secondary prevention of ischemic stroke.

The prevalence among patients with a recent ischemic stroke is ≈70%.

The risk for a first ischemic stroke is directly related to blood pressure (BP)

starting with an SBP as low as 115 mm Hg.

Hypertension Recommendations

1. Initiation of BP therapy is indicated for previously untreated patients with ischemic stroke or TIA who, after the first several days, have an established BP ≥140 mm Hg systolic or ≥90 mm Hg diastolic (Class I; Level of Evidence B). Initiation of therapy for patients with BP <140 mm Hg systolic and <90 mm Hg diastolic is of uncertain benefit (Class IIb; Level of Evidence C). (Revised recommendation)

2. Resumption of BP therapy is indicated for previously treated patients with known hypertension for both prevention of recurrent stroke and prevention of other vascular events in those who have had an ischemic stroke or TIA and are beyond the first several days (Class I; Level of Evidence A). (Revised recommendation)

3. Goals for target BP level or reduction from pretreatment baseline are uncertain and should be individualized, but it is reasonable to achieve a systolic pressure <140 mm Hg and a diastolic pressure <90 mm Hg (Class IIa; Level of Evidence B).

For patients with a recent lacunar stroke, it might be reasonable to target an SBP of <130 mm Hg (Class IIb; Level of Evidence B). (Revised recommendation)

Hypertension Recommendations

4. Several lifestyle modifications have been associated with BP reductions and are a

reasonable part of a comprehensive antihypertensive therapy (Class IIa; Level of

Evidence C).

These modifications include

Salt restriction;

Weight loss;

The consumption of a dietrich in fruits, vegetables, and low-fat dairy products;

Regular aerobic physical activity; and

Limited alcohol consumption.

Hypertension Recommendations

5. The optimal drug regimen to achieve the recommended level of

reductions is uncertain because direct comparisons between

regimens are limited.

The available data indicate that diuretics or the combination of

diuretics and an angiotensin-converting enzyme inhibitor is useful

(Class I; Level of Evidence A).

Hypertension Recommendations

6. The choice of specific drugs and targets should be individualized on

the basis of pharmacological properties, mechanism of action, and

consideration of specific patient characteristics for which specific

agents are probably indicated (eg, extracranial cerebrovascular occlusive

disease, renal impairment, cardiac disease, and DM) (Class IIa; Level of

Evidence B).

Hypertension Recommendations

The management of blood pressure in acute stroke depends on the type of

stroke.

For patients with acute ischemic stroke who will receive thrombolytic

therapy, antihypertensive treatment is recommended so that systolic blood

pressure is ≤185 mmHg and diastolic blood pressure is ≤110 mmHg

Potential approaches to arterial hypertension in patients with acute ischemic stroke who are candidates for acute reperfusion therapy

Patient otherwise eligible for acute reperfusion therapy except that blood pressure is >185/110 mmHg

Labetalol 10 to 20 mg intravenously over 1 to 2 minutes, may repeat one time; or

Nicardipine 5 mg/hour intravenously, titrate up by 2.5 mg/hour every 5 to 15 minutes, maximum 15 mg/hour; when desired blood pressure reached, adjust to maintain proper blood pressure limits; or

Other agents (hydralazine, enalaprilat, etc) may be considered when appropriate

If blood pressure is not maintained at or below 185/110 mmHg, do not administer rtPA

Management to maintain blood pressure at or below 180/105 mmHg during and after acute reperfusion therapy

Monitor blood pressure every 15 minutes for 2 hours from the start of rtPA therapy, then every 30 minutes for 6 hours, and then every hour for 16 hours

If systolic blood pressure is >180 to 230 mmHg or diastolic is >105 to 120 mmHg:

Labetalol 10 mg intravenously followed by continuous infusion 2 to 8 mg/min; or

Nicardipine 5 mg/hour intravenously, titrate up to desired effect by 2.5 mg/hour every 5 to 15 minutes, maximum 15 mg/hour

If blood pressure is not controlled or diastolic blood pressure >140 mmHg, consider intravenous sodium nitroprusside

Disorders of Glucose Metabolism and DMRecommendations

1. After a TIA or ischemic stroke, all patients should probably be screened

for DM with testing of fasting plasma glucose, HbA1c, or an oral glucose

tolerance test.

Choice of test and timing should be guided by clinical judgment and

recognition that acute illness may temporarily perturb measures of plasma

glucose.

In general, HbA1c may be more accurate than other screening tests in the

immediate postevent period (Class IIa; Level of Evidence C). (New

recommendation)

2. Use of existing guidelines from the ADA for glycemic control and

cardiovascular risk factor management is recommended for patients

with an ischemic stroke or TIA who also have DM or pre-DM (Class I;

Level of Evidence B).

Introduction

Stroke ranks as the fourth-leading cause of death in the United States.

Globally, over the past 4 decades, stroke incidence rates have fallen by 42% in high-income countries and increased by >100% in low-and middle-income countries.

Stroke incidence rates in low-and middle-income countries now exceed those in high-income countries

Definition of Classes and Levels of Evidence Used in AHA/ASA Recommendations

Assessing the Risk of First Stroke: Recommendations

The use of a risk assessment tool such as the AHA/ ACC CV Risk Calculator (http://my.americanheart. org/cv risk calculator ) is reasonable because these tools can help identify individuals who could benefit from therapeutic interventions and who may not be treated on the basis of any single risk factor.

These calculators are useful to alert clinicians and patients of possible risk, but basing treatment decisions on the results needs to be considered in the context of the overall risk profile of the patient (Class IIa; Level of Evidence B).

Physical Inactivity: Recommendations

1. Physical activity is recommended

because it is associated with a reduction in the

risk of stroke (Class I; Level of

Evidence B).

2. Healthy adults should perform at least moderate- to vigorous-intensity

aerobic physical activity at least 40 min/d 3 to 4 d/wk(Class I; Level of

Evidence B).

Dyslipidemia: Recommendations

1. In addition to therapeutic lifestyle changes, treatment with an HMG coenzyme-A reductase inhibitor (statin) medication is recommended for the primary prevention of ischemic stroke in patients estimated to have a high 10-year risk for cardiovascular events as recommended in the 2013 “ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults”(Class I; Level of Evidence A).

2. Niacin may be considered for patients with low HDL cholesterol or elevated Lp(a), but its efficacy in preventing ischemic stroke in patients with these conditions is not established. Caution should be used with niacin because it increases the risk of myopathy (Class IIb; Level of Evidence B).

Dyslipidemia: Recommendations

3. Fibric acid derivatives may be considered for patients with hypertriglyceridemia, but their efficacy in preventing ischemic stroke is not established (Class IIb; Level of Evidence C).

4. Treatment with nonstatin lipid-lowering therapies such as fibric acid derivatives, bile acid sequestrants, niacin, and ezetimibe may be considered in patients who cannot tolerate statins, but their efficacy in preventing stroke is not established (Class IIb; Level of Evidence C).

Diet and Nutrition: Recommendations

1. Reduced intake of sodium and increased intake of potassium as indicated in the US Dietary Guidelines for Americans are recommended to lower BP (Class I; Level of Evidence A).

2. A DASH-style diet, which emphasizes fruits, vegetables, and low-fat dairy products and reduced saturated fat, is recommended to lower BP1 (Class I; Level of Evidence A).

3. A diet that is rich in fruits and vegetables and thereby high in potassium is beneficial and may lower the risk of stroke (Class I; Level of Evidence B).

4. A Mediterranean diet supplemented with nuts may be considered in lowering the risk of stroke (Class IIa; Level of Evidence B).

Hypertension: Recommendations

1. Regular BP screening and appropriate

treatment of patients with hypertension, including lifestyle modification and

pharmacological therapy, are recommended (Class

I; Level of Evidence A).

2. Annual screening for high BP and

health-promoting lifestyle

modification are recommended for

patients with prehypertension

(SBP of 120 to 139 mm Hg or DBP of 80 to 89

mm Hg) (Class I; Level of Evidence A).

3. Patients who have hypertension should

be treated with antihypertensive

drugs to a target BP of <140/90 mm Hg (Class I; Level of

Evidence A).

Hypertension: Recommendations

4. Successful reduction of BP is more important in reducing stroke risk than the choice of a specific agent, and treatment should be individualized on the basis of other patient characteristics and medication tolerance (Class I; Level of Evidence A).

5. Self-measured BP monitoring is recommended to improve BP control. (Class I; Level of Evidence A).

Obesity and Body Fat Distribution:Recommendations

1. Among overweight (BMI=25 to 29 kg/m2) and obese (BMI >30 kg/m2) individuals, weight reduction is recommended for lowering BP (Class I; Level of Evidence A).

2. Among overweight (BMI=25 to 29 kg/m2) and obese (BMI >30 kg/m2) individuals, weight reduction is recommended for reducing the risk of stroke (Class I; Level of Evidence B).

Diabetes: Recommendations

1. Control of BP in accordance with an AHA/ACC/ CDC Advisory to a target of <140/90 mm Hg is recommended in patients with type 1 or type 2 diabetes mellitus (Class I; Level of Evidence A).

2. Treatment of adults with diabetes mellitus with a statin, especially those with additional risk factors, is recommended to lower the risk of first stroke (Class I; Level of Evidence A).

Diabetes: Recommendations

3. The usefulness of aspirin for primary stroke prevention for patients with

diabetes mellitus but low 10-year risk of CVD is unclear (Class IIb; Level of

Evidence B).

4. Adding a fibrate to a statin in people with diabetes mellitus is not useful

for decreasing stroke risk (Class III; Level of Evidence B).