Published in Neurology and  1 other channel 

News · February 14, 2019

ISC 2019: 130/80 mm Hg Identified as Likely Best Target for Repeat Stroke Prevention

Intensive blood pressure control particularly important for prevention of hemorrhagic stroke

February 7, 2019—Honolulu, Hawaii—Maintaining a blood pressure under 130/80 mm Hg may help reduce the risk of having a repeat stroke, according to a randomized controlled trial and meta-analysis presented here at the 2019 International Stroke Conference, which took place from February 6 to 8.

“Blood pressure lowering [is] effective for secondary stroke prevention, but the optimum blood pressure has not been determined,” presenter Kazuo Kitagawa, MD, PhD, of Tokyo Women’s Medical University in Japan told Elsevier’s PracticeUpdate.

For the RESPECT study, patients in Japan who had a recent, CT- or MRI-defined symptomatic ischemic or hemorrhagic stroke were randomized in an open-label design to intensive blood pressure control of less than 140/90 mm Hg or intensive blood pressure control of less than 120/80 mm Hg. The primary endpoint was the cumulative incidence of first recurrent stroke, including ischemic stroke and intracerebral hemorrhage.

Patients were recruited between October 2010 and December 2015 in a 1:1 design, with the intention of recruiting 2000 patients. The trial was stopped, however, on December 31, 2016 after enrollment of 1263 patients, due to cessation of funding. Of these patients, 630 in the standard-treatment group and 633 in the intensive-treatment group were followed up for a mean of 3.9 (standard deviation [SD] 1.5) years.

Patients’ mean age was 67 (SD 8.8) years. After 1 year, mean blood pressure was 132.0/77.5 mm Hg (95% confidence interval 130.9 – 133.0/76.6 – 78.3) in the standard target group and 123.7/72.8 mm Hg (95% confidence interval 122.6 – 124.8/72.0 –73.7) in the intensive target group.

Overall, 91 first recurrent strokes occurred. The hazard ratio for cumulative incidence of recurrent stroke with intensive versus standard blood pressure treatment was 0.73 (95% confidence interval 0.49 – 1.11; P = .143). While the hazard ratio in the standard versus intensive blood pressure groups was not significant, at 0.91 (95% confidence interval 0.59 – 1.42; P = .686), for ischemic stroke, it was significant, at 0.09 (95% confidence interval 0.01 – 0.70; P = .021), for intracerebral hemorrhage.

In an updated meta-analysis of randomized trials presented by the study authors that comprised 2454 patients, including the patients from RESPECT, the hazard ratio for the cumulative incidence of recurrent stroke with intensive versus standard blood pressure treatment was 0.78 (95% confidence interval (0.64 – 0.96; P = .016).

“Differences in blood pressure between [the] two group was 8 mm Hg, smaller than expected, and early termination could explain why [the difference in stroke outcomes between the two groups] did not reach statistical significance,” said Dr. Kitagawa. “Nevertheless, when the findings of the RESPECT study were pooled with previous randomized controlled trials, intensive blood pressure treatment was shown to be [effective] for secondary stroke prevention, compared with standard treatment. This is the most important finding. … After we published our results and updated meta-analysis, blood pressure control less than 130/80 mm Hg would be strongly recommended for secondary stroke prevention, as Grade A.”

“Although the event of intracerebral hemorrhage was secondary outcome,” he continued, “[a] marked difference in rate of intracerebral hemorrhage was observed between two groups (hazard radio 0.09). Therefore, we would recommend that patients [at] high risk of intracerebral hemorrhage received intensive blood pressure treatment.”BP