Management of Blood Pressure for Acute and Recurrent Stroke

ypertension is the most important modifiable risk factor for stroke. 1,2It is estimated that 25% or more of strokes may be attributable to hypertension.Because many patients with stroke have mild hypertension or prehypertension, we have shifted our focus and now think of stroke on a continuum of risk based on blood pressure (BP) level rather than on a threshold effect. 3Because high BP may not exist in isolation, a wider definition of hypertension has been proposed that also takes into account the absolute risk of cardiovascular events and associated metabolic factors or early disease markers. 3owering BP reduces the risk of stroke.Epidemiological studies have shown that for each 10 mm Hg lower systolic blood pressure (SBP), there is a decrease in risk of stroke of approximately one third in persons aged 60 to 79 years.This association is continuous down to levels of at least 115/ 75 mm Hg and is consistent across sexes, regions, stroke subtypes, and for fatal and nonfatal events. 4Lowering diastolic blood pressure (DBP) was once the main target to achieve stroke and other cardiovascular event reduction, but SBP has now become the target. 3As recently shown, even the elderly with sustained SBP elevation may gain from BP reduction in relation to less fatal or nonfatal stroke, death, and heart failure. 5lthough the role of longer-term BP control to improve outcomes in patients with stroke is undisputed, BP management immediately after a stroke remains controversial.In an effort to resolve this controversy, several pilot clinical trials have been initiated.In this review, we discuss the results of some of these trials and available evidence-based guidelines for BP control in the settings of acute ischemic and hemorrhagic stroke (excluding subarachnoid hemorrhage) and in recurrent stroke prevention.