Different systolic blood pressure targets for people with history of stroke or transient ischaemic attack: PAST-BP (Prevention After Stroke—Blood Pressure) randomised controlled trial

Mant, Jonathan; McManus, Richard J; Roalfe, Andrea; Fletcher, Kate; Taylor, Clare; Martin, Una; Virdee, Satnam; Greenfield, Sheila; Hobbs, FD Richard

doi:10.1136/bmj.i708

Cited by 59 publications

(69 citation statements)

References 23 publications

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“…After retrieving the full-text version of the aforementioned 21 studies, 1 study was excluded because it did not report data on achieved BP, as well as 6 more studies that included non-IS/TIA population (Table S1 in the online-only Data Supplement). In the final presentation of the literature search results, there was no conflict or disagreement between the 2 reviewers, and the 14 studies that met the study protocol's inclusion criteria [16][17][18][19][20][21][22][23][24][25][26][27][28][29] were included both in the qualitative and quantitative synthesis ( Figure S1). The characteristics of the included studies, comprising a total of 42 736 patients (63.9% men), are summarized in Table 1.…”

Section: Study Selection and Study Characteristicsmentioning

confidence: 99%

“…Included studies consisted of 11 placebo-controlled RCTs, 16 23 In most studies, stroke was defined according to the still used WHO definition 30,31 as a focal neurological deficit of cardiovascular origin persisting for >24 hours. [17][18][19][20][21][22]27 In 5 of the studies, positive neuroimaging was either sufficient by itself 25,26,29 or additional 23,24 to the clinical presentation above for the final definition of stroke. Final, 1 study reported a duration of focal neurological >48 hours for the definition of stroke, 16 whereas another study provided no definition for stroke.…”

Section: Study Selection and Study Characteristicsmentioning

confidence: 99%

“…Overall, the risks of attrition and detection bias were considered unclear because of the absence of adequate report in the methods of many included trials. More specifically, the risk of both performance bias and detection bias was considered high in 2 studies that reported open-label design with lack of any blinding method 22,24 and partially high in a study protocol reporting blinding only in end point evaluation (PROBE design). 23 The risk for reporting bias was judged to be low because study protocols were available in most cases, although published reports from all trials included all expected outcomes.…”

Section: Risk Of Bias For Independent Studiesmentioning

confidence: 99%

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Blood Pressure Reduction and Secondary Stroke Prevention

et al. 2017

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Evidence from randomized controlled trials (RCTs) supports the use of antihypertensive agents in the secondary prevention of patients with ischemic stroke (IS) or transient ischemic attack (TIA).1,2 However, since heterogeneity is present for several outcomes among these trials, current recommendations do not specifically address the intensity of blood pressure (BP) lowering for secondary stroke prevention. 1,2This heterogeneity has been attributed to both a potential class effect of antihypertensive drugs used (related also to the reduction of BP variability) 3 and differences in the degree of BP reduction using standard and aggressive antihypertensive strategies. 4 Moreover, the majority of RCTs of secondary stroke prevention did not specifically evaluate the association between the extent of BP reduction and long-term outcomes in patients with stroke or TIA, leading to increasing uncertainty about the optimal BP levels that should be aimed and achieved during secondary stroke prevention. 5,6 In view of the former considerations, we conducted a systematic review and metaregression analysis on the association of BP reduction with recurrent stroke and cardiovascular events using available RCT data on secondary stroke prevention. Methods Trial Identification and Data AbstractionThis meta-analysis has adopted the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) for systematic reviews and meta-analyses.7 Eligible RCTs of all antihypertensive treatments used in the secondary prevention of IS/TIA Abstract-Current recommendations do not specifically address the optimal blood pressure (BP) reduction for secondary stroke prevention in patients with previous cerebrovascular events. We conducted a systematic review and metaregression analysis on the association of BP reduction with recurrent stroke and cardiovascular events using data from randomized controlled clinical trials of secondary stroke prevention. For all reported events during each eligible study period, we calculated the corresponding risk ratios to express the comparison of event occurrence risk between patients randomized to antihypertensive treatment and those randomized to placebo. The extent of BP reduction is linearly associated with the magnitude of risk reduction in recurrent cerebrovascular and cardiovascular events. Strict and aggressive BP control seems to be essential for effective secondary stroke prevention.

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Section: Study Selection and Study Characteristicsmentioning

confidence: 99%

Section: Study Selection and Study Characteristicsmentioning

confidence: 99%

Section: Risk Of Bias For Independent Studiesmentioning

confidence: 99%

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Blood Pressure Reduction and Secondary Stroke Prevention

et al. 2017

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“…Es gibt weiterhin relativ wenige Studien zur Sekundärprävention nach TIA und Schlaganfall bei Patienten mit erhöhten Blutdruckwerten. Die PAST-BP-Studie untersuchte bei 529 Patienten nach TIA und Schlaganfall eine intensive Blutdrucksenkung mit einem Zielwert von < 130 mmHg versus einem Standardziel von < 140 mmHg [71]. Der mittlere systemische Blutdruck war in der intensiven Behandlungsgruppe nach einem Jahr um 16 mmHg gefallen, in der Standardtherapiegruppe um 13 mmHg.…”

Section: Antihypertensive Therapieunclassified

Neues beim Schlaganfall

et al. 2016

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Zusammenfassung Diese ?bersichtsarbeit fasst neue Erkenntnisse zur Epidemiologie, Diagnostik, Akuttherapie sowie Prim?r- und Sekund?rpr?vention des Schlaganfalls aus den Jahren 2015 und 2016 zusammen. Gro?e epidemiologische Studien zeigen, dass behandelbare Risikofaktoren wie die arterielle Hypertonie, Diabetes mellitus, Rauchen, Bewegungsmangel und Ern?hrung bis zu 90?% des Schlaganfallrisikos erkl?ren. Bei asymptomatischen Karotisstenosen haben die Operation und das Stenting vergleichbare Komplikationsraten. Durch randomisierte Studien und gro?e Register hat sich gezeigt, dass sehr viel mehr Patienten als fr?her f?r eine systemische Thrombolyse mit rt-PA zug?nglich sind. Dies betrifft Patienten im Alter >?80 Jahre, Patienten mit schweren Schlaganf?llen und Patienten mit einem systolischen Blutdruck >?160?mmHg. Auch Patienten mit Dissektionen der hirnversorgenden Arterien profitieren von einer Lyse. Die Lyse kann auch bei Einnahme von nicht-Vitamin-K-abh?ngigen oralen Antikoagulanzien (NOAKs) durchgef?hrt werden, wenn die letzte Einnahme solange zur?ckliegt, dass die Gerinnungswerte normal sind. Die wirksamste Therapie distaler Karotisverschl?sse und Verschl?sse der proximalen Arteria cerebri media ist die Lyse gefolgt von der mechanischen Thrombektomie mit einer NNT von 2,6 f?r einen guten Outcome. Der Thrombozytenfunktionshemmer Ticagrelor war in der fr?hen Pr?vention des isch?mischen Schlaganfalls oder nach Hochrisiko-TIA nicht wirksamer als Azetylsalizyls?ure f?r den kombinierten vaskul?ren Endpunkt aus Schlaganfall, Myokardinfarkt und vaskul?rem Tod. Diese Substanz verhinderte allerdings signifikant isch?mische Insulte. Bei der Therapie zerebraler Blutungen ist bei hohen Blutdruckwerten die Blutdrucksenkung nur marginal wirksam. In der Therapie von durch Vitamin-K-Antagonisten induzierten zerebralen Blutungen ist Prothrombinkomplex (PPSB) besser wirksam als fresh frozen plasma (FFP). Der Verschluss eines offenen Foramen ovale bei Patienten mit kryptogenem Schlaganfall ist nur in Ausnahmef?llen gerechtfertigt.

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“… 8 The trial involved active management in all patients, and found that this led to important reductions in BP in both arms. 9 The more intensive target was associated with only a small additional reduction in BP (2.9 mmHg), which raises the question as to whether such an intensive target is cost effective.…”

Section: Introductionmentioning

confidence: 99%

Cost-effectiveness analysis of different systolic blood pressure targets for people with a history of stroke or transient ischaemic attack: Economic analysis of the PAST-BP study

Penaloza-Ramos

Jowett

Barton

et al. 2016

Eur J Prev Cardiolog

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BackgroundThe PAST-BP trial found that using a lower systolic blood pressure target (<130 mmHg or lower versus <140 mmHg) in a primary care population with prevalent cerebrovascular disease was associated with a small additional reduction in blood pressure (2.9 mmHg).ObjectivesTo determine the cost effectiveness of an intensive systolic blood pressure target (<130 mmHg or lower) compared with a standard target (<140 mmHg) in people with a history of stroke or transient ischaemic attack on general practice stroke/transient ischaemic attack registers in England.MethodsA Markov model with a one-year time cycle and a 30-year time horizon was used to estimate the cost per quality-adjusted life year of an intensive target versus a standard target. Individual patient level data were used from the PAST-BP trial with regard to change in blood pressure and numbers of primary care consultations over a 12-month period. Published sources were used to estimate life expectancy and risks of cardiovascular events and their associated costs and utilities.ResultsIn the base-case results, aiming for an intensive blood pressure target was dominant, with the incremental lifetime costs being £169 lower per patient than for the standard blood pressure target with a 0.08 quality-adjusted life year gain. This was robust to sensitivity analyses, unless intensive blood pressure lowering reduced quality of life by 2% or more.ConclusionAiming for a systolic blood pressure target of <130 mmHg or lower is cost effective in people who have had a stroke/transient ischaemic attack in the community, but it is difficult to separate out the impact of the lower target from the impact of more active management of blood pressure.

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Different systolic blood pressure targets for people with history of stroke or transient ischaemic attack: PAST-BP (Prevention After Stroke—Blood Pressure) randomised controlled trial

Abstract: ObjeCtiveTo assess whether using intensive blood pressure targets leads to lower blood pressure in a community population of people with prevalent cerebrovascular disease. DesignOpen label randomised controlled trial.

Cited by 59 publications

References 23 publications

Blood Pressure Reduction and Secondary Stroke Prevention

Blood Pressure Reduction and Secondary Stroke Prevention

Neues beim Schlaganfall

Cost-effectiveness analysis of different systolic blood pressure targets for people with a history of stroke or transient ischaemic attack: Economic analysis of the PAST-BP study

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