Blood pressure 1 year after stroke: the need to optimize secondary prevention. Lower target blood pressures are safe and effective for the prevention of recurrent stroke: the PROGRESS trial [A prospective study of stroke recurrence and the risk factors]. J-shaped relation between blood pressure and stroke in treated hypertensives. Stroke recurrence The preventing recurrent vascular events and neurological worsening through intensive organized case-management (PREVENTION) trial protocol [clinicaltrials.gov identifier: NCT00931788] Hypotensive therapy in stroke survivors. Tailored interventions to improve hypertension management after stroke or TIA--phase II (TIMS II). 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. Subgroup and per-protocol analysis of the randomized European Trial on Isolated Systolic Hypertension in the Elderly. Long-term prognostic implications of visit-to-visit blood pressure variability in patients with ischemic stroke. Blood pressure declines and less favorable outcomes in the NINDS tPA stroke study Protocol for Past BP: a randomised controlled trial of different blood pressure targets for people with a history of stroke of transient ischaemic attack (TIA) in primary care Utility of electronic patient records in primary care for stroke secondary prevention trials Hypertension management in the Multiple Risk Factor Intervention Trial (MRFIT). Six-year intervention results for men in special intervention and usual care groups. Comparison of the Effects of Antihypertensive Agents on Central Blood Pressure and Arterial Stiffness in Isolated Systolic Hypertension Predictors of adverse outcome among patients with hypertension and coronary artery disease.
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 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 OBJECTIVE To evaluate prognosis of stroke and identify the risk factors for stroke recurrence . METHODS Based on the West China Hospital stroke register data base , we conducted a prospect i ve follow-up study of stroke patients to record the potential risk factors of stroke recurrence and investigate stroke recurrence at 1 year . Analysis of the risk factors was performed using a logistic regression model . RESULTS A total of 1913 stroke consecutive patients admitted to our department were prospect ively registered . Of these patients , 599 ( 31.3 % ) were identified to have intracerebral hemorrhage ( ICH ) , and 1314 ( 68.7 % ) had ischemic stroke . The total recurrence rate at 1 year was 11.2 % , and was 10.5 % in ischemic patients and 12.7 % in ICH patients . Multivariate analysis adjusted for age and gender identified atrial fibrillation , hypertension , hyperlipemia , family history of stroke , and smoking as the risk factors of stroke recurrence at 1 year . CONCLUSION The 1 year recurrent rate is about 11 % , and monitoring the factors of atrial fibrillation , hyperlipemia , hypertension , and smoking may help reduce the recurrence of stroke The objective of this study was to investigate the relationship between  hypertension and risk of stroke in the elderly . The study was performed within the framework of the Rotterdam Study , a prospect i ve population -based cohort study . The risk of first-ever stroke was associated with hypertension ( relative risk , 1.6 ; 95 % CI , 1.2 to 2.0 ) and with isolated systolic hypertension ( relative risk , 1.7 ; 95 % CI , 1.1 to 2.6 ) . We found a continuous increase in stroke incidence with increasing blood pressure in nontreated subjects . In treated subjects , we found a J-shaped relation between blood pressure and the risk of stroke . In the lowest category of diastolic blood pressure , the increase of stroke risk was statistically significant compared with the reference category . Hypertension and isolated systolic hypertension are strong risk factors for stroke in the elderly . The increased stroke risk in the lowest stratum of blood pressure in treated hypertensive patients may indicate that the therapeutic goal of " the lower the better " is not the optimal strategy in the elderly We compared stroke severity , risk factors , and prognosis in patients with recurrent versus first-ever stroke . In the Copenhagen Stroke Study , we prospect ively studied 1,138 unselected patients with acute stroke . Stroke was recurrent in 265 ( 23 % ) despite most of these patients being given prophylactic treatment prior to recurrence . Only 12 % of patients with atrial fibrillation were receiving anticoagulant treatment prior to recurrence . In multivariate analysis , recurrence was more frequently associated with a history of TIA , atrial fibrillation , male gender , and hypertension , but not with age , daily alcohol consumption , smoking , diabetes , ischemic heart disease , serum cholesterol , or hematocrit . Mortality was almost doubled compared with patients with a first-ever stroke . In survivors , however , both neurologic and functional outcomes and the speed of recovery were , in general , similar in the two groups . Despite similar neurologic impairments , patients with recurrence contralateral to their first stroke had markedly more severe functional disability after completed rehabilitation than patients with ipsilateral recurrence , implying that the ability to compensate functionally is decreased in patients with contralateral recurrence . Our findings emphasize the importance of consistent anticoagulant treatment for stroke patients with atrial fibrillation and close blood pressure control in stroke patients with hypertension . Other prophylactic measures are needed in patients in whom ASA fails to prevent recurrence . Patients with recurrent stroke have a markedly higher mortality than patients with a first-ever stroke , but those who survive recover as well and as fast as patients with a first-ever stroke . However , if recurrence is contralateral to the first stroke , functional recovery is poorer 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 Abstract A prospect i ve r and omised controlled trial of hypotensive therapy in 97 hypertensive patients surviving an ischaemic-type stroke was started in 1964 and terminated 4 years later . The patients were under 80 years of age , consecutively admitted to one hospital and the control and treated groups compared well for age , sex , and severity of hypertension . The drugs used were methyldopa , bethanidine or debrisoquine combined with restriction of salt intake , weight reduction , and thiazide diuretics , and the results were analysed with regard to survival and recurrence rates . Hypertension was defined as diastolic if this pressure was 110 mm . Hg or above , and as systolic if this pressure was over 160 mm . Hg with the diastolic below 110 mm . Hg . The mortality-rate at the end of a 2 to 5 year followup was 26 % in the treated group and 46 % in the untreated , and the non-fatal recurrence-rate 14 % in the treated and 23 % in the controls . Good smooth control was essential to success , untreated patients doing better than those whose control was unsatisfactory . In patients aged over 65 treatment of systolic hypertension was of no benefit , although the diastolic hypertensives improved marginally with treatment . As age increased this effect was progressively less apparent but the figures are probably too small to mean anything . In this series significant improvement occurred in treated hypertensive patients who had survived a stroke if they were aged 65 or below , but not if they were older BACKGROUND Reduction of blood pressure ( BP )  after stroke or TIA decreases stroke recurrence and is a major goal of secondary Stroke Prevention Clinics ( SPCs ) . Health care providers need effective screening processes to identify those clients at highest risk of not achieving BP targets and those clients at highest risk ofnon-adherence to medication . METHODS This multicentred , r and omized controlled study used a screening process to identify SPC patients with psychosocial/cognitive deficits ( e.g. , lack of confidence in the utility of medications , poor memory , mild cognitive impairment ) who were experiencing difficulty managing their BP to target values and evaluated whether a model of nurse-led case management program ( monthly telephone calls , motivational interviewingfor lifestyle change , plus home BP monitoring and use ofdosettes for medication administration ) would improve BP measures and adherence to medications . RESULTS Both  intervention ( n=29 ) and usual care  groups ( n=27 ) showed a trend-for'reduced BP at six months ( Median ql-q3 , Systolic BR p=0.46 ; Diastolic BR p=0.37 ) . Diabetic patients , irrespective of the group to which they were r and omized , were less likely to meet Best Practice Guideline targets than those without diabetes ( Chi Square test , p=0.0001 ) . CONCLUSION Stroke and TIA patients with diabetes may require additional re sources and support in order to reach BP target values 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 BACKGROUND In 1989 , the European Working Party on High Blood Pressure in the Elderly started the double-blind , placebo-controlled , Systolic Hypertension in Europe Trial to test the hypothesis that antihypertensive drug treatment would reduce the incidence of fatal and nonfatal stroke in older patients with isolated systolic hypertension . This report addresses whether the benefit of antihypertensive treatment varied according to sex , previous cardiovascular complications , age , initial blood pressure ( BP ) , and smoking or drinking habits in an intention-to-treat analysis and explores whether the morbidity and mortality results were consistent in a per- protocol analysis . METHODS After stratification for center , sex , and cardiovascular complications , 4695 patients 60 years of age or older with a systolic BP of 160 to 219 mm Hg and diastolic BP less than 95 mm Hg were r and omized . Active treatment consisted of nitrendipine ( 10 - 40 mg/d ) , with the possible addition of enalapril maleate ( 5 - 20 mg/d ) and /or hydrochlorothiazide ( 12.5 - 25 mg/d ) , titrated or combined to reduce the sitting systolic BP by at least 20 mm Hg , to below 150 mm Hg . In the control group , matching placebo tablets were employed similarly . RESULTS In the intention-to-treat analysis , male sex , previous cardiovascular complications , older age , higher systolic BP , and smoking at r and omization were positively and independently correlated with cardiovascular risk . Furthermore , for total ( P = .009 ) and cardiovascular ( P = .09 ) mortality , the benefit of antihypertensive drug treatment weakened with advancing age ; for total mortality ( P = .05 ) , the benefit increased with higher systolic BP at entry , while for fatal and nonfatal stroke ( P = .01 ) , it was most evident in nonsmokers ( 92.5 % of all patients ) . In the per protocol analysis , active treatment reduced total mortality by 24 % ( P = .05 ) , reduced all fatal and nonfatal cardiovascular end points by 32 % ( P<.001 ) , reduced all strokes by 44 % ( P = .004 ) , reduced nonfatal strokes by 48 % ( P = .005 ) , and reduced all cardiac end points , including sudden death , by 26 % ( P = .05 ) . CONCLUSIONS In elderly patients with isolated systolic hypertension , stepwise antihypertensive drug treatment , starting with the dihydropyridine calcium channel blocker nitrendipine , improves prognosis . The per- protocol analysis suggested that treating 1000 patients for 5 years would prevent 24 deaths , 54 major cardiovascular end points , 29 strokes , or 25 cardiac end points . The effects of antihypertensive drug treatment on total and cardiovascular mortality may be attenuated in very old patients 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 BACKGROUND AND PURPOSE Hypertension is the most important modifiable risk factor for secondary stroke prevention but the immediate management of blood pressure after stroke is uncertain . We evaluated outcomes in the NINDS tPA stroke study in relation to blood pressure declines during the first 24 h after r and omization . METHODS Declines in blood pressure compared to baseline and preceding time points were analyzed in relationship to favorable outcomes ( by a global test ) , poor outcomes ( Rankin scale > 3 ) and death at 3 months . RESULTS 551 patients did not receive immediate pre-r and omization anti-hypertensive treatment and had available blood pressures . Multivariate analysis showed significantly and progressively reducing likelihoods of a favorable outcome with each 10 mmHg decline in systolic blood pressure ( SBP ) > 50 mmHg compared to any preceding measurement . Poor outcomes were significantly more likely in patients with > 50 mmHg SBP reduction ( or > 30 mmHg compared to any immediately preceding measurement ) . There was an increased risk of death with blood pressure declines > 60 mmHg . tPA treatment still produced favorable outcomes compared with placebo even with blood pressure declines . The median largest SBP reduction from baseline in patients treated with tPA was 35 mmHg compared to 30 mmHg in placebo-treated patients ( p<0.01 ) . CONCLUSIONS In this post hoc analysis , progressively reducing likelihoods of a favorable outcome were seen with increasing declines in SBP . Despite a greater likelihood of favorable outcomes , tPA treatment was associated with a greater reduction in blood pressure than placebo . R and omized trials of blood pressure management are needed Background Blood pressure ( BP ) lowering in people who have had a stroke or transient ischaemic attack ( TIA ) leads to reduced risk of further stroke . However , it is not clear what the target BP should be , since intensification of therapy may lead to additional adverse effects . PAST BP will determine whether more intensive BP targets can be achieved in a primary care setting , and whether more intensive therapy is associated with adverse effects on quality of life . Methods / Design This is a r and omised controlled trial ( RCT ) in patients with a past history of stroke or TIA . Patients will be r and omised to two groups and will either have their blood pressure ( BP ) lowered intensively to a target of 130 mmHg systolic , ( or by 10 mmHg if the baseline systolic pressure is between 125 and 140 mmHg ) compared to a st and ard group where the BP will be reduced to a target of 140 mmHg systolic . Patients will be managed by their practice at 1 - 3 month intervals depending on level of BP and followed-up by the research team at six monthly intervals for 12 months.610 patients will be recruited from approximately 50 general practice s. The following exclusion criteria will be applied : systolic BP < 125 mmHg at baseline , 3 or more anti-hypertensive agents , orthostatic hypotension , diabetes mellitus with microalbuminuria or other condition requiring a lower treatment target or terminal illness . The primary outcome will be change in systolic BP over twelve months . Secondary outcomes include quality of life , adverse events and cardiovascular events . In-depth interviews with 30 patients and 20 health care practitioners will be undertaken to investigate patient and healthcare professionals underst and ing and views of BP management . Discussion The results of this trial will inform whether intensive blood pressure targets can be achieved in people who have had a stroke or TIA in primary care , and help determine whether or not further research is required before recommending such targets for this population .Trial Registration IS RCT Background This study aim ed to inform the design of a pragmatic trial of stroke prevention in primary care by evaluating data recorded in electronic patient records ( EPRs ) as potential outcome measures . The study also evaluated achievement of recommended st and ards of care ; variation between family practice s ; and changes in risk factor values from before to after stroke . Methods Data from the UK General Practice Research Data base ( GPRD ) were analysed for 22,730 participants with an index first stroke between 2003 and 2006 from 414 family practice s. For each subject , the EPR was evaluated for the 12 months before and after stroke . Measures relevant to stroke secondary prevention were analysed including blood pressure ( BP ) , cholesterol , smoking , alcohol use , body mass index ( BMI ) , atrial fibrillation , utilisation of antihypertensive , antiplatelet and cholesterol lowering drugs . Intraclass correlation coefficients ( ICC ) were estimated by family practice . R and om effects models were fitted to evaluate changes in risk factor values over time . Results In the 12 months following stroke , BP was recorded for 90 % , cholesterol for 70 % and body mass index ( BMI ) for 47 % . ICCs by family practice ranged from 0.02 for BP and BMI to 0.05 for LDL and HDL cholesterol . For subjects with records available both before and after stroke , the mean reductions from before to after stroke were : mean systolic BP , 6.02 mm Hg ; diastolic BP , 2.78 mm Hg ; total cholesterol , 0.60 mmol/l ; BMI , 0.34 Kg/m2 . There was an absolute reduction in smokers of 5 % and heavy drinkers of 4 % . The proportion of stroke patients within the recommended guidelines varied from less than a third ( 29 % ) for systolic BP , just over half for BMI ( 54 % ) , and over 90 % ( 92 % ) on alcohol consumption . Conclusions Electronic patient records have potential for evaluation of outcomes in pragmatic trials of stroke secondary prevention . Stroke prevention interventions in primary care remain suboptimal but important reductions in vascular risk factor values were observed following stroke . Better recording of lifestyle factors in the GPRD has the potential to exp and the scope of the GPRD for health care research and practice The Multiple Risk Factor Intervention Trial was a large collaborative primary prevention trial design ed to test the effects of lowering cardiovascular risk factors ( ie , diastolic blood pressure [ DBP ] , serum cholesterol , and cigarette smoking ) on mortality rate from coronary heart disease in 12,866 high-risk men aged 35 to 57 years . Men were r and omly assigned to either special intervention ( SI ) or usual care ( UC ) groups . Usual care men were referred to their regular source of medical care . Special intervention men were seen frequently and underwent intensive intervention initially followed by maintenance intervention in 22 different clinical centers . Hypertension intervention in SI men primarily consisted of a stepped-care pharmacologic approach design ed to lower blood pressure ( BP ) . After six years , 58.2 % of SI men and 47.0 % of UC men were given  antihypertensive medication . In both study groups , mean systolic and diastolic BPs decreased from baseline ; after six years , overall DBP was 3.2 mm Hg lower in SI men compared with UC men . In hypertensive men ( DBP greater than or equal to 90 mm Hg or those taking antihypertensive medication at baseline ) , after six years , DBP was 4.4 mm Hg lower in the SI group compared with the UC group . Use of specific antihypertensive agents differed substantially between the two groups . Self-reported complaints while taking antihypertensive drugs were minimal in both groups . Weight loss was associated with BP lowering in both study groups , regardless of treatment status Isolated systolic hypertension is an important risk factor for cardiovascular disease and results primarily from elastic artery stiffening . Although various drug therapies are used to lower peripheral blood pressure ( BP ) in patients with isolated systolic hypertension , the effects of the 4 major classes of antihypertensive agents on central BP , pulse pressure ( PP ) amplification , and arterial stiffness in this condition are not clear . Fifty-nine patients over the age of 60 years with untreated isolated systolic hypertension ( systolic BP ≥140 mm Hg and diastolic BP ≤90 mm Hg ) were r and omly assigned to receive 1 of the following 4 antihypertensive agents : perindopril , atenolol , lercanidipine , or bendrofluazide  . BP was measured using a mercury sphygmomanometer , and augmentation index and carotid-femoral ( aortic ) pulse wave velocity were measured at baseline , after 2 weeks of placebo therapy , and at the end of 10 weeks of active therapy . Peripheral systolic BP and peripheral PP were reduced similarly after treatment with all 4 classes of drug . However , central PP was only reduced significantly by perindopril , lercanidipine , and bendrofluazide , whereas atenolol had no effect . Lercanidipine reduced the augmentation index , whereas atenolol increased it . Aortic pulse wave velocity was not changed by any of the drugs . In summary , despite similar reductions in peripheral systolic and PPs with the 4 classes of drug , changes in central pressure and augmentation index varied . Because central PP and increased wave reflections are considered important risk factors in patients with isolated systolic hypertension , the choice of therapy may be influenced by these findings in the future OBJECTIVES We sought to determine predictors for adverse outcomes in hypertensive patients with coronary artery disease ( CAD ) . BACKGROUND Factors leading to adverse outcomes in hypertensive patients with CAD are poorly understood . The INternational VErapamil-tr and olapril STudy ( INVEST ) compared outcomes in hypertensive patients with CAD that were assigned r and omly to either a verapamil sustained-release (SR)- or an atenolol-based strategy for blood pressure ( BP ) control . Tr and olapril and hydrochlorothiazide were used as added agents . During follow-up ( 61,835 patient-years ) , BP control and the primary outcome ( death , nonfatal myocardial infa rct ion , and nonfatal stroke ) were not different between strategies . METHODS We investigated risk for adverse outcome associated with baseline factors , follow-up BP , and drug treatments using Cox modeling . RESULTS Previous heart failure ( adjusted hazard ratio [ HR ] 1.96 ) , as well as diabetes ( HR 1.77 ) , increased age ( HR 1.63 ) , U.S. residency ( HR 1.61 ) , renal impairment ( HR 1.50 ) , stroke/transient ischemic attack ( HR 1.43 ) , smoking ( HR 1.41 ) , myocardial infa rct ion ( HR 1.34 ) , peripheral vascular disease ( HR 1.27 ) , and revascularization ( HR 1.15 ) predicted increased risk . Follow-up systolic BP < 140 mm Hg or diastolic BP < 90 mm Hg ( HRs 0.82 or 0.70 , respectively ) and tr and olapril with verapamil SR ( HRs 0.78 and 0.79 ) were associated with reduced risk . CONCLUSIONS In hypertensive patients with CAD , increased risk for adverse outcomes was associated with conditions related to the severity of CAD and diminished left ventricular function . Lower follow-up BP and addition of tr and olapril to verapamil SR each were associated with reduced risk
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 .