ht and stroke, 2012
TRANSCRIPT
HT and StrokeA treatment strategy
in neurology perspective
Surat Tanprawate, MD, FRCP(T), MSc(London)Division of Neurology, Chiang Mai University
Outline of my talk
Introduction to stroke risk factors
HT and stroke
BP target
Medication choice
Role of RAS inhibitor
Combination therapy
Apoplexy; Struck down with violenceStroke of God hand
Global burden of strokestroke is cause...disability (no. 1), dementia (no. 2), death (no. 3)
Johnston et al Lancet Neurol 2009
Thai stroke data...
•Public health statistic A.D. 2005
• Third cause of death
•Prevalence Thai stroke: 1,850/100,000
Classification of Ischemic stroke
original ‘TOAST classification; 1993’
Large artery atherosclerosis
Lacunar stroke(<1.5 cm)
Cardioembolism
Others
Albers et al. Chest 2004;126(3 Suppl):438S-512S
20%
25%
20%
Since 1948
Probability of stroke: a risk profile from the Framingham Study
Stroke. 1991;22:312-318Framingham risk score
Systolic Diastolic
Hypertension: Pathophysiology, Diagnosis, and Management.1995:127–144.
Stroke death rate by categories of systolic blood pressure and diastolic blood pressure.
Stroke death rate by categories of systolic blood pressure and diastolic
blood pressure.
Hypertension: Pathophysiology, Diagnosis, and Management.1995:127–144.
Stroke death rate by categories of systolic blood pressure and diastolic blood pressure.
Hypertension: Pathophysiology, Diagnosis, and Management.1995:127–144.
Treatment of Blood pressure
• Increase BP increase risk of stroke
• 5 mm Hg(DBP): ) 33% increase in stroke
• BP reduction of 5-6 mm Hg reduction
DBP(10-12 mm Hg SBP) reduce the risk of
stroke by 35-40%The RISC Group. Lancet.1990;335: 827-830
Neal B. MacMahon S. J Hypertens.1995; 13:1869-1873
Systematic review of 7 randomized trials of pharmacological blood-pressure-lowering treatment in patients with a prior stroke or TIA
Rashid P, Leonardi-Bee J. Stroke2003; 34(11):2741–8.
2 Large RCTPROGRESS studyPATS study
Blood pressure management in stroke
Guideline
Primary prevention
Secondary prevention
BP target
Drug choice
Stroke 2011;42;517-584
Primary Prevention of Stroke
Antihypertensive for primary stroke prevention
• In a meta-analysis of 23 randomized trials with stroke outcomes, antihypertensive drug treatment reduced risk of stroke by 32% (95% CI, 24% to 39%; P0.004) in comparison with no drug treatment
• No definitive evidence that any class of antihypertensive agents offers special protection against stroke
Stroke 2011;42;517-584
Stroke 2011;42;227-276
Secondary Prevention of Stroke
ASA/AHA guideline• An absolute target BP level and reduction are uncertain
and should be individualized, but benefit has been associated with an average reduction of approximately
10/5 mm Hg, and normal BP levels have been defined as 120/80 mm Hg by JNC 7 (Class IIa; Level B)
• 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 diabetes) (Class IIa; Level B). (New recommendation)
Stroke 2011;42;227-276
RAS and role of ACEI, ARB
J Mol Med (2008) 86:715–722
ACEI
ARB
HOPE Study
-32%
Ramipril vs
Placebo
ARBs reduce risk of first stroke
►9,193 hypertensives for mean 4.8 years
►Blood pressure reduction (SBP/DBP mmHg) was 30/17 and 29/17 in the Losartan and Atenolol arms, respectively
Favoursatenolol
Favourslosartan
Primarycompositeendpoint
Cardiovascularmortality
Stroke Myocardialinfarction
Dahlöf et al. Lancet 2002;359:995–1003
LIFE study: Losartan vs AtenololA
dju
sted h
aza
rd r
ati
o
(95%
CI)
0.6
0.8
1.0
1.2
1.4
25% decrease stroke
Cardiovascular morbidity and mortality in patients with diabetes in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE)
PROGRESS Study
Clinical evidence in secondary stroke prevention with RAS block
Progress study
• Perindopril vs Placebo
ProFess study
• Telmisartan vs Placebo
MOSES study
• Candesartan vs Nitrendipine
ONTARGET study
• Telmisartan vs Ramipril
In Reality
RAS blockade has clearly benefit beyond BP reduction for preventing stroke
ARB needs more clinical trial for proving clinical effectiveness over ACEI
ARB is less side effect than ACEI
Real situation
J Manag Care Pharm. 2007;13(8)(suppl S-b):S2-S8
What is the problem?
Therapeutic Inertia
Patient compliance
Combination BP lowering agent
Health Effects of Diuretics
• 3,081 Japanese patients with hypertension, CHD and/or HF
• Valsartan added to conventional non-ARB therapy versus supplementary conventional non-ARB treatment
ARB vs Non-ARB based therapy in Japanese patients
Thank You For Your Kind Attention
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