Perindopril-Based Blood Pressure–Lowering Reduces Major Vascular Events in Patients With Atrial Fibrillation and Prior Stroke or Transient Ischemic Attack

BACKGROUND AND PURPOSE: Patients with atrial fibrillation have a high risk of stroke and other vascular events even if anticoagulated. The primary objective here is to determine whether routine blood pressure-lowering provides additional protection for this high-risk patient group. METHODS: This study was a subsidiary analysis of the Perindopril Protection Against Recurrent Stroke Study (PROGRESS)--a randomized, placebo-controlled trial that established the beneficial effects of blood pressure--lowering in a heterogeneous group of patients with cerebrovascular disease. A total of 6105 patients were randomly assigned to either active treatment (2 to 4 mg perindopril for all participants plus 2.0 to 2.5 mg indapamide for those without an indication for or a contraindication to a diuretic) or matching placebo(s). Outcomes are total major vascular events, cause-specific vascular outcomes, and death from any cause. RESULTS: There were 476 patients with atrial fibrillation at baseline, of whom 51% were taking anticoagulants. In these patients, active treatment lowered mean blood pressure by 7.3/3.4 mm Hg and was associated with a 38% (95% confidence interval CI, 6 to 59) reduction in major vascular events and 34% (95% CI, -13 to 61) reduction in stroke. The benefits of blood pressure-lowering in patients with atrial fibrillation were achieved irrespective of the use of anticoagulant therapy (P homogeneity=0.8) or the presence of hypertension (P homogeneity=0.4). CONCLUSIONS: For most patients with atrial fibrillation, routine blood pressure-lowering is likely to provide protection against major vascular events additional to that conferred by anticoagulation.