Blood pressure reduction for the secondary prevention of stroke: a Chinese trial and a systematic review of the literature

Abstract

We assessed, in a double-blind, placebo-controlled trial, whether lowering blood pressure (BP) prevents the recurrence of stroke in Chinese patients with cerebrovascular disease. Patients were randomized into two groups: 2825 patients received a placebo and 2840 patients received 2.5 mg of indapamide daily. The primary and secondary outcomes were the recurrence of fatal or nonfatal stroke and major fatal and nonfatal cardiovascular events, respectively. The average systolic/diastolic BP at randomization was 153.8/92.8 mm Hg. At median follow-up (2 years), BP was, on an average, 6.8/3.3 mm Hg lower in patients on active treatment. In total, 143 patients on indapamide and 219 patients on placebo had recurrent strokes (hazard ratio for indapamide, 0.69; 95% confidence interval (CI): 0.54-0.89; Po0.001). In addition, 199 patients on indapamide and 258 patients on placebo had a cardiovascular event (hazard ratio, 0.75; 95% CI: 0.89-0.62; P¼0.002). We performed a systematic review of literature that included our new results. Across 10 trials, the odds ratio for the prevention of stroke recurrence by BP lowering was 0.78 (95% CI: 0.68-0.90; P¼0.0007). The pooled odds ratio was 0.63 (95% CI: 0.54-0.73; Po0.0001) for trials involving diuretics as a component of therapy and 0.93 (95% CI: 0.87-1.01; P¼0.086) for trials in which treatment included renin system inhibitors (Po0.0001 for heterogeneity). The weighted correlation between the odds for stroke recurrence and the reduction in systolic BP was À0.57 (P¼0.067). In conclusion, BP lowering by indapamide treatment reduced the recurrence of stroke and the incidence of cardiovascular events in Chinese patients with cerebrovascular disease. Whether prevention of stroke recurrence depends on drug class, degree of BP lowering or both requires further investigation.

Combination therapy for hypertension in the elderly: a sub-analysis of the Combination Therapy of Hypertension to Prevent Cardiovascular Events (COPE) Trial

“…20 However, the benefit of BP reduction regarding the risk of stroke was demonstrated in elderly patients treated for hypertension with thiazide-based therapy. 4,[21][22][23][24][25][26] Furthermore, late elderly hypertensive patients (X80 years old) showed a 30% reduction of the risk of stroke in association with the reduction of all-cause mortality during indapamide-based treatment. 4 It is also reported that CCBs favor the prevention of stroke compared with regimens based on diuretics or bblockers.…”

Treatment of Risk Factors to Prevent Stroke

“…In secondary prevention of stroke, blood pressure lowering is clearly effective and important, and appears to confirm that stroke is reduced by~40% by reduction of SBP by 10 mmHg [14]. However, are anti-hypertensives given to persons with stroke who have normal BP helpful in preventing strokes?…”

“…However, are anti-hypertensives given to persons with stroke who have normal BP helpful in preventing strokes? The normotensive subgroup in the Post-Stroke Antihypertensive Treatment Study seems to suggest this to be as a result [14], and a recent meta-analysis suggest that antihypertensives given to normotensive individuals with prior cardiovascular disease or its risk equivalent (i.e., stroke, CHD, congestive heart failure (CHF), or diabetes mellitus) reduced risk of stroke by 23% [15]. However, the results should be interpreted with caution because the meta-analysis found heterogeneity among studies, and two other secondary stroke prevention studies after stroke, namely the Perindopril Protection against Recurrent Stroke Study (PROGRESS) and the Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS) study, did not find significant stroke reduction among normotensive persons [16,17].…”

“…The meta-regression analyses results suggested superiority of a calcium channel blocker in comparison with beta-blockers [6]. Another meta-analysis comparing diuretics to renin-angiotensin inhibitors in secondary stroke prevention concluded greater effect seen in diuretics than renin-angiotensin inhibitors [14]. However, before focusing on the idea that 1 drug class is superior to another, it is important to note that more 50% of persons with hypertension need more than 1 antihypertensive drug in clinical practice [20].…”

Indapamide retard as the medication of choice in elderly patients with arterial hypertension

“…В исследовании PATS у пациентов, принимавших индапамид, удалось достичь сниже-ния повторных инсультов на 31%. В исследовании PROGRESS применение комбинированной терапии, включавшей индапамид и периндоприл, позволило на 55% снизить количество перенесенных повторных инсультов [10].…”