Level of systolic blood pressure within the normal range and risk of recurrent stroke

Metabolic Syndrome and Ischemic Stroke in Iran: Incidence and Disability-Adjusted Life Years 1990 to 2019

Introduction: Metabolic syndrome (MS) is one of the conditions that may increase the risk of ischemic stroke (IS). This study focuses on factors of MS related to the incidence, years of life lost (YLL), and years of life disability (YLD) caused by IS. Materials and Methods: The age-adjusted data (incidence, YLL, and YLD) related to four factors of MS [fasting plasma glucose, body mass index (BMI), low-density lipoprotein, and systolic blood pressure, SBP] were extracted as risk factors for IS during the years 1990 to 2019 from global burden of disease study. ARC GIS V.10 software was used to investigate the geographical distribution and the Cochran-Armitage test was used to investigate the trend of these indices. Results: The highest incidence of IS was reported in Golestan provinces in 2019 [women: 180 (95% UI 153-213), men: 163 (95% UI 141-191), and both genders: 172 (95% UI 149-201)]. High SBP has the highest impact on YLD (96-102 per 100,000 population in some provinces) and YLL (688-824 per 100,000 population in some provinces) in men and women (YLD: 126-156, YLL: 586-785 per 100,000 population in some provinces). High BMI has increased YLD caused by IS from 1990 (35 per 100,000 population) to 2019 (53 per 100,000 population). Conclusion: Considering the importance of IS and the impact that MS has on this disease, it seems that one of the most effective possible measures is to eliminate MS. The factors of MS are mostly related to lifestyle, and MS can be controlled with a suitable plan, which can be considered as primary prevention for IS.

European stroke organisation (ESO) guideline on cerebral small vessel disease, part 2, lacunar ischaemic stroke

A quarter of ischaemic strokes are lacunar subtype, typically neurologically mild, usually resulting from intrinsic cerebral small vessel pathology, with risk factor profiles and outcome rates differing from other stroke subtypes. This European Stroke Organisation (ESO) guideline provides evidence-based recommendations to assist with clinical decisions about management of lacunar ischaemic stroke to prevent adverse clinical outcomes. The guideline was developed according to ESO standard operating procedures and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. We addressed acute treatment (including progressive lacunar stroke) and secondary prevention in lacunar ischaemic stroke, and prioritised the interventions of thrombolysis, antiplatelet drugs, blood pressure lowering, lipid lowering, lifestyle, and other interventions and their potential effects on the clinical outcomes recurrent stroke, dependency, major adverse cardiovascular events, death, cognitive decline, mobility, gait, or mood disorders. We systematically reviewed the literature, assessed the evidence and where feasible formulated evidence-based recommendations, and expert concensus statements. We found little direct evidence, mostly of low quality. We recommend that patients with suspected acute lacunar ischaemic stroke receive intravenous alteplase, antiplatelet drugs and avoid blood pressure lowering according to current acute ischaemic stroke guidelines. For secondary prevention, we recommend single antiplatelet treatment long-term, blood pressure control, and lipid lowering according to current guidelines. We recommend smoking cessation, regular exercise, other healthy lifestyle modifications, and avoid obesity for general health benefits. We cannot make any recommendation concerning progressive stroke or other drugs. Large randomised controlled trials with clinically important endpoints, including cognitive endpoints, are a priority for lacunar ischaemic stroke.

Real-world analysis of two ischaemic stroke and TIA systolic blood pressure goals on 12-month mortality and recurrent vascular events

INTRODUCTION

Whether obtaining the more intensive goal systolic blood pressure (SBP) of <130 mm Hg, rather than a less intensive SBP goal of <140 mm Hg poststroke/transient ischaemic attack (TIA) is associated with incremental mortality and recurrent vascular event benefit is largely unexplored using real-world data. Lowering SBP excessively may result in poorer outcomes.

METHODS

This is a retrospective cohort study of 26 368 Veterans presenting to a Veterans Administration Medical Center (VAMC) with a stroke/TIA between October 2015 and July 2018. Patients were excluded from the study if they had missing or extreme BP values, receiving dialysis or palliative care, left against medical advice had a cancer diagnosis, were cared for in a VAMC enrolled in a stroke/TIA quality improvement initiative, died or had a cerebrovascular or cardiovascular event within 90 days after their index stroke/TIA. The analytical sample included 12 337 patients. Average SBP during 90 days after discharge was assessed in categories (≤105 mm Hg, 106-115 mm Hg, 116-130 mm Hg, 131-140 mm Hg and >140 mm Hg). Separate multivariable Cox proportional hazard regressions were used to examine the relationship between average SBP groups and time to: (1) mortality and (2) any recurrent vascular event, from 90 days to up to 365 days after discharge from the index emergency department visit or inpatient admission.

RESULTS

Compared with those with SBP>140 mm Hg, patients with SBP between 116 and 130 mm Hg had a significantly lower risk of recurrent stroke/TIA (HR 0.77, 95% CI 0.60 to 0.99) but not cardiovascular events. Patients with SBP lower than 105 mm Hg, compared with those with >140 mm Hg demonstrated a statistically significant higher risk of death (HR 2.07, 95% CI 1.43 to 3.00), but no statistical differences were found in other SBP groups.

DISCUSSION

Data support a more intensive SBP goal to prevent recurrent cerebrovascular events among stroke/TIA patients by 90 days poststroke/TIA compared with less intensive goal. Very low SBPs were associated with increased mortality risk.

Improving Stroke Risk Factor Management Focusing on Health Disparities and Knowledge Gaps

Stroke is a leading cause of death and disability in the United States and worldwide, necessitating comprehensive efforts to optimize stroke risk factor management. Health disparities in stroke incidence, prevalence, and risk factor management persist among various race/ethnic, geographic, and socioeconomic populations and negatively impact stroke outcomes. This review highlights existing literature and guidelines for stroke risk factor management, emphasizing health disparities among certain populations. Moreover, stroke risk factors for special groups, including the young, the very elderly, and pregnant/peripartum women are outlined. Strategies for stroke risk factor improvement at every level of the health care system are discussed, from the individual patient to providers, health care systems, and policymakers. Improving stroke risk factor management in the context of the social determinants of health, and with the goal of eliminating inequities and disparities in stroke prevention strategies, are critical steps to reducing the burden of stroke and equitably improving public health.

Associations between long-term blood pressure trajectory and all-cause and CVD mortality among old people in China

Background

Optimal blood pressure (BP) management strategy among the elderly remains controversial, with insufficient consideration of long-term BP trajectory. This study aimed to identify BP trajectory patterns as well as terminal BP trajectory among the Chinese elderly and to explore the relationships between BP trajectories and all-cause mortality and cardiovascular disease (CVD) mortality.

Methods

We included 11,181 participants older than 60 at baseline (mean age, 80.98 ± 10.71) with 42,871 routine BP measurements from the Chinese Longitudinal Healthy Longevity Survey. Latent class trajectory analysis and Cox proportional hazard model were conducted to identify trajectory patterns and their associations with mortality. Furthermore, we also applied mixed-effects model to identify terminal BP trajectories among the elderly.

Results

Compared with stable at normal high level trajectory, excess systolic BP (SBP) trajectory with decreasing trend was associated with a 34% (HR = 1.34, 95% CI: 1.23-1.45) higher risk of all-cause mortality. Considering the competing risk of non-CVD death, excess BP trajectory with decreasing trend had a more pronounced effect on CVD mortality, in which HR (95% CI) was 1.67 (1.17, 2.37). Similar results were also found in diastolic BP (DBP), pulse pressure (PP), and mean arterial pressure (MAP) trajectories. We further conducted a mixed-effects model and observed that SBP and PP trajectories first increased and began to decline slightly six years before death. In contrast, DBP and MAP showed continuous decline 15 years before death.

Conclusion

Long-term BP trajectory was associated with all-cause mortality, especially CVD mortality. Keeping a stable BP over time may be an important way for CVD prevention among the elderly.

War and Health Care Services Utilization for Chronic Diseases in Rural and Semiurban Areas of Tigray, Ethiopia

Importance

The war in Tigray, Ethiopia, has disrupted the health care system of the region. However, its association with health care services disruption for chronic diseases has not been well documented.

Objective

To assess the association of the war with the utilization of health care services for patients with chronic diseases.

Design, Setting, and Participants

Of 135 primary health care facilities, a registry-based cross-sectional study was conducted on 44 rural and semiurban facilities of Tigray. Data on health services utilization were extracted for patients with tuberculosis, HIV, diabetes, hypertension, and psychiatric disorders in the prewar period (September 1, to October 31, 2020) and during the first phase of the war period (November 4, 2020, to June 30, 2021).

Main Outcomes and Measures

Records on the number of follow-up, laboratory tests, and patients undergoing treatment of the aforementioned chronic diseases were counted during the prewar and war periods.

Results

Of 4645 records of patients with chronic diseases undergoing treatment during the prewar period, 998 records (21%) indicated having treatment during the war period. Compared with the prewar period, 59 of 180 individuals (33%; 95% CI, 26%-40%) had tuberculosis, 522 of 2211 (24%; 95% CI, 22%-26%) had HIV, 228 of 1195 (19%; 95% CI, 17%-21%) had hypertension, 123 of 632 (20%; 95% CI, 16%-22%) had psychiatric disorders, and 66 of 427 (15%; 95% CI, 12%-18%) had type 2 diabetes records, which revealed continued treatment during the war period. Of 174 records of patients with type 1 diabetes in the prewar period, at 2 to 3 months into the war, the numbers dropped to 10 with 94% decline compared with prewar observations.

Conclusions and Relevance

This study found that the war in Tigray has resulted in critical health care service disruption and high loss to follow-up for patients with chronic disease, likely leading to increased morbidity and mortality. Local, national, and global policymakers must understand the extent and impact of the service disruption and urge their efforts toward restoration of those services.

The impact of the COVID-19 pandemic on blood pressure control after a stroke or transient ischemic attack among patients at VA medical centers

OBJECTIVE

To study factors associated with systolic blood pressure(SBP) control for patients post-discharge from an ischemic stroke or transient ischemic attack(TIA) during the early months of the COVID-19 pandemic compared to pre-pandemic periods within the Veterans Health Administration(VHA).

MATERIALS AND METHODS

We analyzed retrospective data from patients discharged from Emergency Departments or inpatient admissions after an ischemic stroke or TIA. Cohorts consisted of 2,816 patients during March-September 2020 and 11,900 during the same months in 2017-2019. Outcomes included primary care or neurology clinic visits, recorded blood pressure readings and average blood pressure control in the 90-days post-discharge. Random effect logit models were used to compare clinical characteristics of the cohorts and relationships between patient characteristics and outcomes.

RESULTS

The majority (73%) of patients with recorded readings during the COVID-19 period had a mean post-discharge SBP within goal (<140 mmHg); this was slightly lower than the pre-COVID-19 period (78%; p=0.001). Only 38% of the COVID-19 cohort had a recorded SBP in the 90-days post-discharge compared with 83% of patients during the pre-pandemic period (p=0.001). During the pandemic period, 29% did not have follow-up primary care or neurologist visits, and 33% had a phone or video visit without a recorded SBP reading.

CONCLUSIONS

Patients with an acute cerebrovascular event during the initial COVID-19 period were less likely to have outpatient visits or blood pressure measurements than during the pre-pandemic period; patients with uncontrolled SBP should be targeted for follow-up hypertension management.

Association Between Magnitude of Differential Blood Pressure Reduction and Secondary Stroke Prevention: A Meta-analysis and Meta-Regression

Importance

The degree to which more intensive blood pressure reduction is better than less intensive for secondary stroke prevention has not been delineated.

Objective

To perform a standard meta-analysis and a meta-regression of randomized clinical trials to evaluate the association of magnitude of differential blood pressure reduction and recurrent stroke in patients with stroke or transient ischemic attack (TIA).

Data Sources

PubMed, Embase, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched from January 1, 1980, to June 30, 2022.

Study Selection

Randomized clinical trials that compared more intensive vs less intensive blood pressure lowering and recorded the outcome of recurrent stroke in patients with stroke or TIA.

Data Extraction and Synthesis

The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was used for abstracting data and assessing data quality and validity. Risk ratio (RR) with 95% CI was used as a measure of the association of more intensive vs less intensive blood pressure lowering with primary and secondary outcomes. The univariate meta-regression analyses were conducted to evaluate a possible moderating effect of magnitude of differential systolic blood pressure (SBP) and diastolic blood pressure (DBP) reduction on the recurrent stroke and major cardiovascular events.

Main Outcomes and Measures

The primary outcome was recurrent stroke and the lead secondary outcome was major cardiovascular events.

Results

Ten randomized clinical trials comprising 40 710 patients (13 752 women [34%]; mean age, 65 years) with stroke or TIA were included for analysis. The mean duration of follow-up was 2.8 years (range, 1-4 years). Pooled results showed that more intensive treatment compared with less intensive was associated with a reduced risk of recurrent stroke in patients with stroke or TIA (absolute risk, 8.4% vs 10.1%; RR, 0.83; 95% CI, 0.78-0.88). Meta-regression showed that the magnitude of differential SBP and DBP reduction was associated with a lower risk of recurrent stroke in patients with stroke or TIA in a log-linear fashion (SBP: regression slope, -0.06; 95% CI, -0.08 to -0.03; DBP: regression slope, -0.17; 95% CI, -0.26 to -0.08). Similar results were found in the association between differential blood pressure lowering and major cardiovascular events.

Conclusions and Relevance

More intensive blood pressure-lowering therapy might be associated with a reduced risk of recurrent stroke and major cardiovascular events. These results might support the use of more intensive blood pressure reduction for secondary prevention in patients with stroke or TIA.

Wearable Two-Dimensional Nanomaterial-Based Flexible Sensors for Blood Pressure Monitoring: A Review

Flexible sensors have been extensively employed in wearable technologies for physiological monitoring given the technological advancement in recent years. Conventional sensors made of silicon or glass substrates may be limited by their rigid structures, bulkiness, and incapability for continuous monitoring of vital signs, such as blood pressure (BP). Two-dimensional (2D) nanomaterials have received considerable attention in the fabrication of flexible sensors due to their large surface-area-to-volume ratio, high electrical conductivity, cost effectiveness, flexibility, and light weight. This review discusses the transduction mechanisms, namely, piezoelectric, capacitive, piezoresistive, and triboelectric, of flexible sensors. Several 2D nanomaterials used as sensing elements for flexible BP sensors are reviewed in terms of their mechanisms, materials, and sensing performance. Previous works on wearable BP sensors are presented, including epidermal patches, electronic tattoos, and commercialized BP patches. Finally, the challenges and future outlook of this emerging technology are addressed for non-invasive and continuous BP monitoring.

Blood Pressure Control Targets and Risk of Cardiovascular and Cerebrovascular Events After Intracerebral Hemorrhage

BACKGROUND

Intracerebral hemorrhage (ICH) survivors are at high risk for recurrent stroke and cardiovascular events. Blood pressure (BP) control represents the most potent intervention to lower these risks, but optimal treatment targets in this patient population remain unknown. We sought to determine whether survivors of ICH achieving more intensive BP control than current guideline recommendations (systolic BP <130 mmHg and diastolic BP <80 mmHg) were at lower risk of major adverse cardiovascular and cerebrovascular events and mortality.

METHODS

We analyzed data for 1828 survivors of spontaneous ICH from 2 cohort studies. Follow-up BP measurements were recorded 3 and 6 months after ICH, and every 6 months thereafter. Outcomes of interest were major adverse cardiovascular and cerebrovascular events (recurrent ICH, incident ischemic stroke, myocardial infarction), vascular mortality (defined as mortality attributed to recurrent ICH, ischemic stroke, or myocardial infarction), and all-cause mortality.

RESULTS

During a median follow-up of 46.2 months, we observed 166 recurrent ICH, 68 ischemic strokes, 69 myocardial infarction, and 429 deaths. Compared with survivors of ICH with systolic BP 120 to 129 mmHg, participants who achieved systolic BP <120 mmHg displayed reduced risk of recurrent ICH (adjusted hazard ratio [AHR], 0.74 [95% CI, 0.59-0.94]) and major adverse cardiovascular and cerebrovascular events (AHR, 0.69 [95% CI, 0.53-0.92]). All-cause mortality (AHR, 0.76 [95% CI, 0.57-1.03]) and vascular mortality (AHR, 0.68 [95% CI, 0.45-1.01]) did not differ significantly. Among participants aged >75 years or with modified Rankin Scale score 4 to 5, systolic BP <120 mmHg was associated with increased all-cause mortality (AHR, 1.38 [95% CI, 1.02-1.85] and AHR, 1.36 [95% CI, 1.03-1.78], respectively), but not vascular mortality. We found no differences in outcome rates between survivors of ICH with diastolic BP <70 versus 70 to 79 mmHg.

CONCLUSIONS

Targeting systolic BP <120 mmHg in select groups of survivors of ICH could result in decreased major adverse cardiovascular and cerebrovascular events risk without increasing mortality. Our findings warrant investigation in dedicated randomized controlled trials.

A coupled atrioventricular-aortic setup for in-vitro hemodynamic study of the systemic circulation: Design, fabrication, and physiological relevancy

In-vitro models of the systemic circulation have gained a lot of interest for fundamental understanding of cardiovascular dynamics and for applied hemodynamic research. In this study, we introduce a physiologically accurate in-vitro hydraulic setup that models the hemodynamics of the coupled atrioventricular-aortic system. This unique experimental simulator has three major components: 1) an arterial system consisting of a human-scale artificial aorta along with the main branches, 2) an artificial left ventricle (LV) sac connected to a programmable piston-in-cylinder pump for simulating cardiac contraction and relaxation, and 3) an artificial left atrium (LA). The setup is designed in such a way that the basal LV is directly connected to the aortic root via an aortic valve, and to the LA via an artificial mitral valve. As a result, two-way hemodynamic couplings can be achieved for studying the effects that the LV, aorta, and LA have on each other. The collected pressure and flow measurements from this setup demonstrate a remarkable correspondence to clinical hemodynamics. We also investigate the physiological relevancies of isolated effects on cardiovascular hemodynamics of various major global parameters found in the circulatory system, including LV contractility, LV preload, heart rate, aortic compliance, and peripheral resistance. Subsequent control over such parameters ultimately captures physiological hemodynamic effects of LV systolic dysfunction, preload (cardiac) diseases, and afterload (arterial) diseases. The detailed design and fabrication of the proposed setup is also provided.

Intersectoral Actions for the Promotion and Prevention of Obesity, Diabetes and Hypertension in Brazilian Cities: A Systematic Review and Meta-Analysis

This study showed the effectiveness of biomedical interventions in obesity, diabetes and hypertension (NCDs), but innovative and intersectoral elements in the fight against obesity, type 2 diabetes and hypertension were rare.

BACKGROUND

Is it possible to find effective and innovative actions to promote health and prevent NCDs in Brazilian municipalities? Can they be replicated?

OBJECTIVE

Our objectives were to identify innovative and effective intersectoral actions for promoting and preventing NCDs in Brazilian municipalities.

METHODS

This is a systematic review in an exploratory theoretical essay with a qualitative and quantitative approach. It is descriptive and analytical in terms of reporting findings and results. Inclusion and exclusion criteria favored health promotion work. Bias risk assessments was performed using the Cochrane GRADE and bias risk, with meta-analyses using RevMan and Iramuteq.

RESULTS

Meta-analysis of biometric markers resulted in -4.46 [95% IC; -5.42, -3.49], p = 0.00001, indicating a reduction in NCD risk rates. The textual meta-analysis revealed P(r) ≈ 83% (Reinert), meaning low connectivity between the 'halos'.

CONCLUSIONS

There is evidence of the effectiveness in interventions, but innovative and intersectoral elements to combat and prevent NCDs were barely seen. While evidence of intervention effectiveness was observed, innovative and intersectoral elements to combat and prevent NCDs were barely noticed.

Blood Pressure Trajectories and Outcomes for Veterans Presenting at VA Medical Centers with a Stroke or Transient Ischemic Attack

BACKGROUND

Blood pressure control has been shown to reduce risk of vascular events and mortality after an ischemic stroke or transient ischemic attack (TIA). Yet, questions remain about effectiveness, timing, and targeted blood pressure reduction.

METHODS

We analyzed data from a retrospective cohort of 18,837 veterans cared for 12 months prior and up to 12 months after an emergency department visit or inpatient admission for stroke or TIA. Latent class growth analysis was used to classify patients into systolic blood pressure trajectories. With Cox proportional hazard models, we examined relationships between blood pressure trajectories, intensification of antihypertensive medication, and stroke (fatal or non-fatal) and all-cause mortality in 12 months following the index event.

RESULTS

The cohort was classified into 4 systolic blood pressure trajectories: 19% with a low systolic blood pressure trajectory (mean systolic blood pressure = 116 mm Hg); 65% with a medium systolic blood pressure trajectory (mean systolic blood pressure = 136 mm Hg); 15% with a high systolic blood pressure trajectory (mean systolic blood pressure = 158 mm Hg), and 1% with a very high trajectory (mean systolic blood pressure = 183 mm Hg). After the stroke or TIA, individuals in the high and very high systolic blood pressure trajectories experienced a substantial decrease in systolic blood pressure that coincided with intensification of antihypertensive medication. Patients with very low and very high systolic blood pressure trajectories had a significantly greater (P < .05) hazard of mortality, while medication intensification was related significantly (P < .05) to lower hazard of mortality.

CONCLUSIONS

These findings point to the importance of monitoring blood pressure over multiple time points and of instituting enhanced hypertension management after stroke or TIA, particularly for individuals with high or very high blood pressure trajectories.

2021 Taiwan Stroke Society Guidelines of blood pressure control for ischemic stroke prevention

BACKGROUND

Since the publication of the 2015 Taiwan Stroke Society Blood Pressure for Treatment and Prevention of Stroke Guideline (2015 TSS BP Guideline), several new clinical studies have addressed whether a stricter blood pressure (BP) target would be effective for stroke prevention.

METHODS

TSS guideline consensus group provides recommendations on BP targets for stroke prevention based on updated evidences.

RESULTS

The present guideline covers five topics: (1) diagnosis of hypertension; (2) BP control and primary prevention of ischemic stroke; (3) BP control and secondary prevention of ischemic stroke; (4) BP control and secondary prevention of large artery atherosclerosis ischemic stroke; and (5) BP control and secondary prevention of small vessel occlusion ischemic stroke.

CONCLUSION

The BP target for most stroke patients with hypertension is <130/80 mm Hg.

Stroke Risk Factors of Stroke Patients in China: A Nationwide Community-Based Cross-Sectional Study

Background: Stroke is the leading cause of death in China, and its burdens are rapidly increasing. The prevalence and control of stroke risk factors among stroke patients in China are unknown. Objective: We investigated the stroke risk factors of stroke patients in China. Design: We examined stroke risk factors in 6580 stroke patients aged 18 years or older in the China National Chronic Diseases and Nutrition Surveillance of Adults (2015–2017). With regard to the basic characteristics of the study participants, categorical variables were described as frequency (percent). The chi-square test was used to analyze the difference between men and women. The multivariate logistic regression model was used in the multivariate analysis. Results: Among the 6580 stroke patients, hypertension was the most common stroke risk factor identified in most cases (78.51%), followed by overweight or obesity (61.58%), dyslipidemia (54.38%), smoking (24.04%), diabetes (21.75%), family history of stroke (17.43%), lack of exercise (16.35%), and atrial fibrillation (4.47%). Drinking stroke patients had a lower rate of hypertension, diabetes, and dyslipidemia. Patients with hyperuricemia had a higher rate of hypertension and dyslipidemia than no-hyperuricemia patients. The hypertension awareness, treatment, and control rates among hypertension stroke patients were 73.62%, 70.19%, and 17.79%, respectively. The diabetes awareness, treatment, and control rates among diabetes patients were 69.74%, 65.83%, and 34.59%, respectively. The dyslipidemia awareness, treatment, and control rates among dyslipidemia patients were 42.37%, 29.4%, and 20.07%, respectively. Among treated hypertension patients, the rates of taking medicine as medically advised, controlled diet, increased exercise, and blood pressure monitoring were 91.31%, 58.88%, 45.78%, and 73.99%, respectively. Among treated diabetes patients, the rates of oral antidiabetic medications, insulin injection, diet control, and blood glucose monitoring were 78.24%, 34.71%, 85.77%, and 78.24%, respectively. Among treated dyslipidemic patients, the rate of taking medicine as medical advice, controlled diet, increased exercise, and regular blood lipid monitoring was 80.61%, 77.57%, 56.46%, and 40.3%, respectively. Conclusions: The most common risk factors for community stroke patients in China are hypertension, dyslipidemia, and overweight or obesity. The stroke community patients’ suboptimal awareness and treatment of hypertension, and suboptimal awareness, treatment, and control of diabetes, and dyslipidemia are significant problems in China.

Long-Term Secondary Prevention: Management of Blood Pressure After a Transient Ischemic Attack or Stroke

Reducing blood pressure (BP) is a highly effective strategy for long-term stroke prevention. Despite overwhelmingly clear evidence from randomized trials that antihypertensive therapy substantially reduces the risk of stroke in primary prevention, uncertainty still surrounds the issue of BP lowering after cerebrovascular events, and the risk of recurrent stroke, coronary events, and vascular death remains significant. Important questions in a secondary prevention setting include should everyone be treated regardless of their poststroke BP, how soon after a stroke should BP-lowering treatment be commenced, how intensively should BP be lowered, what drugs are best, and how should long-term BP control be optimized and monitored. We review the evidence on BP control after a transient ischemic attack or stroke to address these unanswered questions and draw attention to some recent developments that hold promise to improve management of BP in current practice.

Low Blood Pressure, Comorbidities, and Ischemic Stroke Mortality in US Veterans

BACKGROUND AND PURPOSE

Low blood pressure (BP) is associated with higher stroke mortality, although the factors underlying this association have not been fully explored. We investigated prestroke BP and long-term mortality after ischemic stroke in a national sample of US veterans.

METHODS

Using a retrospective cohort study design of veterans hospitalized between 2002 and 2007 with a first ischemic stroke and with ≥1 outpatient BP measurements 1 to 18 months before admission, we defined 6 categories each of average prestroke systolic BP (SBP) and diastolic BP, and 7 categories of pulse pressure. Patients were followed-up to 12 years for primary outcomes of all-cause and cardiovascular mortality. We used Cox models to relate prestroke BP indices to mortality and stratified analyses by the presence of preexisting comorbidities (smoking, myocardial infarction, heart failure, atrial fibrillation/flutter, cancer, and dementia), race and ethnicity.

RESULTS

Of 29 690 eligible veterans with stroke (mean±SD age 67±12 years, 98% men, 67% White), 2989 (10%) had average prestroke SBP<120 mm Hg. During a follow-up of 4.1±3.3 years, patients with SBP<120 mm Hg experienced 61% all-cause and 27% cardiovascular mortality. In multivariable analyses, patients with the lowest SBP, lowest diastolic BP, and highest pulse pressure had the highest mortality risk: SBP<120 versus 130 to 139 mm Hg (hazard ratio=1.26 [95% CI, 1.19-1.34]); diastolic BP <60 versus 70 to 79 mm Hg (hazard ratio=1.35 [95% CI, 1.23-1.49]); and pulse pressure ≥90 versus 60 to 69 mm Hg (hazard ratio=1.24 [95% CI, 1.15-1.35]). Patients with average SBP<120 mm Hg and at least one comorbidity (smoking, heart disease, cancer, or dementia) had the highest mortality risk (hazard ratio=1.45 [95% CI, 1.37-1.53]).

CONCLUSIONS

Compared with normotension, low prestroke BP was associated with mortality after stroke, particularly among patients with at least one comorbidity.

One-Year Blood Pressure Trajectory After Acute Ischemic Stroke

Background Although the effect of blood pressure on poststroke outcome is well recognized, the long-term trajectory of blood pressure after acute ischemic stroke and its influence on outcomes have not been studied well. Methods and Results We analyzed systolic blood pressure (SBP) measurements in 5514 patients with acute ischemic stroke at ≥2 of 7 prespecified time points during the first year after stroke among those enrolled in a multicenter prospective registry. Longitudinal SBPs were categorized using a group-based trajectory model. The primary outcome was a composite of stroke recurrence, myocardial infarction, and all-cause mortality up to 1 year after stroke. The study subjects were categorized into 4 SBP trajectory groups: low (27.0%), moderate (59.5%), persistently high (1.2%), and slowly dropping (12.4%). In the first 3 groups, SBP decreased during the first 3 to 7 days and remained steady thereafter. In the slowly dropping SBP group, SBPs decreased from 182 to 135 mm Hg during the first 30 days, then paralleled the trajectory of the moderate SBP group. Compared with the reference, the moderate SBP group, the slowly dropping SBP group was at higher risk for the primary outcome (adjusted hazard ratio [HR], 1.32; 95% CI, 1.05‒1.65) and mortality (adjusted HR, 1.35; 95% CI, 1.03‒1.78). Primary outcome rates were similarly high in the persistently high SBP group. Conclusions Four 1-year longitudinal SBP trajectories were identified in patients with acute ischemic stroke. Patients in the slowly dropping SBP and persistently high SBP trajectory groups were prone to adverse cardiovascular outcomes after stroke.

Increased mortality with intensive control in patients with higher baseline SBP and lower Framingham risk

OBJECTIVE

In the Systolic Blood Pressure Intervention Trial (SPRINT), the relative reduction in primary outcome with intensive blood pressure (BP) control was numerically smallest in the highest baseline SBP tertile. In this post hoc analysis of SPRINT, the goal was to explore whether the effects of intensive BP treatment varied among patients with different baseline SBP and cardiovascular risks.

METHODS

Patient-level data from 9361 randomized participants in SPRINT were used. Heterogeneity between treatment and patient characteristics were examined stratified by different baseline SBP levels. Cumulative incidences of primary outcome and all-cause death were compared between treatment groups for patients with baseline SBP at least 160 mmHg and lower Framingham risk.

RESULTS

For participants with a baseline SBP of at least 160 mmHg, intensive treatment was associated with a higher rate of all-cause death as compared with standard treatment (1.86 vs. 1.62% per year). After adjustment for age and sex, intensive treatment was associated with significantly increased all-cause death compared with standard treatment [hazard ratio (95% CI) for intensive group: 3.12 (1.00-9.69); P = 0.049] in participants with an SBP of at least 160 mmHg and a Framingham risk score of 31.3% or less (average of median and geometric mean). Patient outcomes were otherwise similar regarding age, use of antihypertensive therapy, cardiovascular disease or chronic kidney disease.

CONCLUSION

Among the SPRINT participants with a baseline SBP of at least 160 mmHg and a lower Framingham risk score, targeting an SBP of less than 120 mmHg compared with less than 140 mmHg resulted in a significantly higher rate of all-cause death.

Blood pressure undulation of peripheral thrombolysis period in acute ischemic stroke is associated with prognosis

BACKGROUND

Evidence suggests that patients with higher blood pressure variability (BPV) have a higher risk for stroke but the relationship between BPV and stroke outcomes is unknown in those who underwent intravenous thrombolysis (IVT) for acute ischemic stroke (AIS). The objective of this study is to investigate the association among BPV, BP values and stroke outcomes.

METHODS

A retrospective analysis of about 510 consecutive thrombolysis cases for AIS from January 2015 to March 2019 in a single-center database were done. Then, these patients were followed-up for 3 months. We used univariate and multivariable models to evaluate the relationship between mean BP values, BPV and the risk of stroke outcomes from prior IVT to 72 h after IVT. Meanwhile, we also used COX regression to assess the hazard ratios of stroke outcomes with BPV within 3 months. Furthermore, we tested the effect of BP level at various time-points (prior to IVT and at 0, 2, 4, 8, 12, 24, 48 and 72 h after IVT) on development of postthrombolytic stroke outcomes.

RESULTS

Higher BPV from prior IVT to 72 h after IVT was associated with higher risk of stroke outcomes within 3 months [SBPV of recurrent stroke: odds ratios (OR) = 5.298, 95% confidence interval (CI) 1.339-10.968, P = 0.018; DBPV of recurrent stroke: OR = 6.397, 95% CI 1.576-25.958, P = 0.009, respectively]. In addition, patients with recurrent stroke had significantly higher mean SBP (OR=1.037, 95% CI 1.006-1.069, P = 0.019). Furthermore, higher BP at different time points were associated with greater risk of recurrent stroke from prior IVT to 72 h after IVT.

CONCLUSION

Higher BPV and SBP from prior IVT to 72 h after IVT was associated with higher risk of stroke outcomes within 3 months.

Stroke Prevention After Intracerebral Hemorrhage: Where Are We Now?

PURPOSE OF REVIEW

Patients after intracerebral hemorrhage (ICH) are at high risk of both ischemic stroke and recurrent ICH, and stroke prevention after ICH is important to improve the long-term outcomes in this patient population. The objective of this article is to review the current guidelines on stroke prevention measures after ICH as well as the new findings and controversies for future guidance.

RECENT FINDINGS

Intensive blood pressure reduction might benefit ICH survivors significantly. Cholesterol levels and the risk of ICH have an inverse relationship, but statin therapy after ICH might be still beneficial. Anticoagulation in atrial fibrillation after ICH specifically with novel oral anticoagulants may be associated with better long-term outcomes. Left atrial appendage occlusion may be an alternative for stroke prevention in ICH survivors with atrial fibrillation for whom long-term anticoagulation therapy is contraindicated. While complete individualized risk assessment is imperative to prevent stroke after ICH, future research is required to address current controversies and knowledge gap in this topic.

"Lessons Learned" Preventing Recurrent Ischemic Strokes through Secondary Prevention Programs: A Systematic Review

Recurrent ischemic strokes are a cause of significant healthcare burdens globally. Patients with uncontrolled vascular risk factors are more likely to develop recurrent ischemic strokes. This study aims to compile information gained from current secondary prevention programs. A pre-defined literature search strategy was applied to PubMed, SCOPUS, CINAHL, and Google Scholar databases, and studies from 1997 to 2020 were evaluated for quality, study aims, and outcomes. The search produced 1175 articles (1092 after duplicates were removed) and titles were screened; 55 titles were retained for the full-text analysis. Of the remaining studies, 31 were retained for assessment, five demonstrated long-term effectiveness, eight demonstrated short-term effectiveness, and 18 demonstrated no effectiveness. The successful studies utilized a variety of different techniques in the categories of physical fitness, education, and adherence to care plans to reduce the risk of recurrent strokes. The lessons we learned from the current prevention programs included (1) offer tailored care for underserved groups, (2) control blood pressure, (3) provide opportunities for medication dosage titration, (4) establish the care plan prior to discharge, (5) invest in supervised exercise programs, (6) remove barriers to accessing care in low resource settings, and (7) improve the transition of care.

The J-Curve Association Between Blood Pressure and Mortality in Stroke Survivors

Purpose

The optimal blood pressure (BP) targets in terms of mortality risk after stroke remain unclear. This study aimed to assess the relationship between BP and mortality in stroke survivors.

Patients and Methods

We included 1696 participants with self-reported history of stroke aged 18 years and older from the National Health and Nutrition Examination Survey (NHANES) 1999–2014 and NHANES III with public-use linked mortality files from 2015. Baseline systolic BP (SBP) and diastolic BP (DBP) levels were obtained by taking the average of 3 measures. Cox proportional hazard models and restricted cubic splines were conducted to explore the relationship between BP and all-cause mortality.

Results

During a median follow-up period of 5.6 years, 888 deaths occurred. After fully adjusting for confounding factors, SBP displayed a J-curve relationship (nadir 135 mm Hg), while DBP exhibited a reverse J-curve relationship (nadir 73 mm Hg) with the risk of all-cause mortality. However, the J-curve or reverse J-curve pattern between blood pressure and mortality appeared to be limited to individuals with an age >65 years, identifying a nadir of SBP/DBP of 142/73 mm Hg. The risk of mortality followed a linear relationship for SBP and DBP in stroke survivors aged ≤65 years, with risks increasing with higher SBP and lower DBP.

Conclusion

In this cross-sectional study that used national survey data, these data suggest a strong J-curve or reverse J-curve relationship between blood pressure and risk of all-cause mortality, whereas the pattern appears to be limited to individuals with an age >65 years, with a nadir at 142/73 mmHg. However, missing data on stroke type and stroke treatment limits the generalizability. Future prospective studies are needed to determine preferential blood pressure target in patients after stroke.

Epidemiological features of hypertension among ischemic survivors in Northeast China: insights from a population-based study, 2017-2019

BACKGROUND

Hypertension remains the major modifiable risk factor of stroke recurrence. The study aimed to determine the up-to-date epidemiological features of hypertension among the survivors of ischemic stroke.

METHODS

Our cross-sectional study included 18,796 adults aged ≥40 years and residing in northeast China. Ischemic stroke was diagnosed according to the World Health Organization's criteria, which requires the clinical record, computed tomography (CT) and/or magnetic resonance imaging (MRI) during the hospital stay. Hypertension was defined according to the Chinese hypertension guidelines (mean SBP ≥140 mmHg and/or mean DBP ≥90 mmHg, and/or self-reported use of anti-hypertensive medication in the past 2 weeks).

RESULTS

Of the 986 survivors of ischemic stroke, 819 (83.1%) were identified with hypertension (535 were pre-stroke hypertension and 284 were post-stroke hypertension). Among hypertensive patients, the awareness and treatment rates were 76.8 and 66.7% respectively. Only 11.0% achieved an appropriate blood pressure (< 140 mmHg and < 90 mmHg) among those who took hypertensive medications. 16.8% of treated hypertensive patients received combination therapy, and calcium channel blockers were the most frequently used anti-hypertensive medication as monotherapy. The mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) of the stroke population was 155.3 ± 22.9 mmHg and 89.2 ± 12.3 mmHg. Both SBP and DBP were higher in rural patients than in urban patients (158.5 ± 23.8 mmHg vs. 146.4 ± 17.5 mmHg and 90.3 ± 12.9 mmHg vs. 85.9 ± 10.1 mmHg, respectively; p < 0.001). The rates of stage 2 and above hypertension in the ischemic stroke population were 32.5 and 18.7%, and was significantly higher in rural areas than in urban areas.

CONCLUSIONS

The prevalence of poorly-controlled hypertension and the high rates of blood pressures at stages 2 and above in patients with prior ischemic stroke demonstrated an alarming situation in northeast China.

Correlation between Stroke Risk and Systolic Blood Pressure in Patients over 50 Years with Uncontrolled Hypertension: Results from the SYSTUP-India Study

Objectives

To assess mean systolic and diastolic blood pressure (SBP and DBP) levels in patients ≥50 years with uncontrolled hypertension (HTN) and evaluate the correlation between BP and stroke risk. It also assessed therapeutic drug classes prescribed in these patients.

Methods

A cross-sectional, observational study was conducted at 176 outpatient centers across India, including patients aged ≥50 years with elevated SBP (≥140 mmHg). The relationship between stroke risk, calculated using Stroke Riskometer™, and mean SBP, mean DBP, and other risk factors was evaluated using Pearson correlation coefficient and logistic regression analysis.

Results

The study included 3791 patients (men, 60.0%; mean age: 62.1 ± 8.3 years; mean BMI: 27 kg/m²) with mean SBP 157.3 ± 12.8 mmHg and mean DBP 89.8 ± 9.7 mmHg. Five-year stroke risk in 33.9% and 10-year stroke risk in 70% patients were moderate to severe. A ~4% increase in both 5- and 10-year stroke risk with each 1 mmHg increase in mean SBP (p < 0.0001) was seen. However, mean DBP did not exhibit any significant correlation with 5-year (p = 0.242) or 10-year (p = 0.8038) stroke risk. There was a positive correlation between mean SBP and patient age, comorbid diabetes, and smoking and alcohol habits (p < 0.0001). Comorbid diabetes and smoking increased 5- and 10-year stroke risk by 2- to 5-fold. Irrespective of the risk category, most patients received antihypertensive therapy with an angiotensin receptor blocker.

Conclusion

Findings corroborate an association between stroke risk and mean SBP. These real-world clinical findings indicate that efforts are required to improve primary prevention of stroke and reduce the prevalence of recurrent stroke in India.

Trends in Antihypertensive Medication Use Among Individuals With a History of Stroke and Hypertension, 2005 to 2016

Importance

Hypertension is a well-established, modifiable risk factor for stroke. National hypertension management trends among stroke survivors may provide important insight into secondary preventive treatment gaps.

Objective

To investigate the adequacy of blood pressure control among stroke survivors and antihypertensive treatment trends using National Health and Nutrition Examination Survey (NHANES) data.

Design, Setting, and Participants

Cross-sectional surveys conducted between 2005 and 2016 of nationally representative samples of the civilian US population were analyzed from March 2019 to January 2020. The NHANES is a large, nationally representative cross-sectional survey conducted in 2-year cycles in the United States. Evaluations include interviews, medication lists, physical examinations, and laboratory tests on blood samples. Among 221 982 140 adults 20 years or older in the NHANES from 2005 through 2016, a total of 4 971 136 had stroke and hypertension and were included in this analysis, with 217 011 004 excluded from the primary analysis.

Exposures

Hypertension was defined by self-report, antihypertensive medication use, or uncontrolled blood pressure (>140/90 mm Hg) on physical examination. Antihypertensive medication was classified as angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, diuretics, β-blockers, calcium channel blockers, or other.

Main Outcomes and Measures

Weighted frequencies and means were reported using NHANES methods, estimating the proportion of individuals with stroke and hypertension. For all other analyses, 4 971 136 individuals with stroke and hypertension were examined, summarizing number and classes of antihypertensive medications, frequency of uncontrolled hypertension, and associations between antihypertensive classes and blood pressure control. Trends in antihypertensive medication use over time were examined.

Results

Among 4 971 136 individuals with a history of stroke and hypertension, the mean age was 67.1 (95% CI, 66.1-68.1) years, and 2 790 518 (56.1%) were women. In total, 37.1% (33.5%-40.8%) had uncontrolled blood pressure on examination, with 80.4% (82.0%-87.5%) taking antihypertensive medication. The most commonly used antihypertensive medications were angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (59.2%; 95% CI, 54.9%-63.4%) and β-blockers (43.8%; 95% CI, 40.3%-47.3%). Examining trends over time, diuretics have become statistically significantly less commonly used (49.4% in 2005-2006 vs 35.7% in 2015-2016, P = .005), with frequencies of other antihypertensive classes remaining constant.

Conclusions and Relevance

In this cross-sectional study that used national survey data, substantial undertreatment of hypertension was found in individuals with a history of stroke, and more than one-third had uncontrolled hypertension. Because hypertension is a major risk factor for stroke, these data demonstrate a missed opportunity nationally for secondary stroke prevention.

Initial in-hospital heart rate is associated with three-month functional outcomes after acute ischemic stroke

Background

Increased heart rate (HR) has been associated with stroke risk and outcomes.

Material and methods

We analyzed 1,420 patients from a hospital-based stroke registry with acute ischemic stroke (AIS). Mean initial in-hospital HR and the coefficient of variation of HR (HR-CV) were derived from the values recorded during the first 3 days of hospitalization. The study outcome was the 3-month functional outcome. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated using multivariable logistic regression analysis.

Results

A higher mean HR level was significantly and continuously associated with a higher probability of unfavorable functional outcomes. Compared with the reference group (mean HR < 70 beats per minute), the multivariate-adjusted OR for an unfavorable outcome was 1.81 (95% CI, 1.25–2.61) for a mean HR ≥ 70 and < 80 beats per minute, 2.52 (95% CI, 1.66 − 3.52) for a mean HR ≥ 80 and < 90 beats per minute, and 3.88 (95% CI, 2.20–6.85) for mean HR ≥ 90 beats per minute. For stroke patients with a history of hypertension, the multivariate-adjusted OR for patients with a HR-CV ≥ 0.12 (versus patients with a HR-CV < 0.08 as a reference) was 1.73 (95% CI, 1.11–2.70) for an unfavorable outcome.

Conclusions

Our results indicated that a high initial in-hospital HR was significantly associated with unfavorable 3-month functional outcomes in patients with AIS. In addition, stroke patients with a HR-CV ≥ 0.12 also had unfavorable outcomes compared with those with a HR-CV < 0.08 if they had a history of hypertension.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02252-2.

Relationship Between Blood Pressure and Incident Cardiovascular Disease: Linear and Nonlinear Mendelian Randomization Analyses

Supplemental Digital Content is available in the text.

Observational studies exploring whether there is a nonlinear effect of blood pressure on cardiovascular disease (CVD) risk are hindered by confounding. This limitation can be overcome by leveraging randomly allocated genetic variants in nonlinear Mendelian randomization analyses. Based on their association with blood pressure traits in a genome-wide association study of 299 024 European ancestry individuals, we selected 253 genetic variants to proxy the effect of modifying systolic and diastolic blood pressure. Considering the outcomes of incident coronary artery disease, stroke and the combined outcome of CVD, linear and nonlinear Mendelian randomization analyses were performed on 255 714 European ancestry participants without a history of CVD or antihypertensive medication use. There was no evidence favoring nonlinear relationships of genetically proxied systolic and diastolic blood pressure with the cardiovascular outcomes over linear relationships. For every 10-mm Hg increase in genetically proxied systolic blood pressure, risk of incident CVD increased by 49% (hazard ratio, 1.49 [95% CI, 1.38–1.61]), with similar estimates obtained for coronary artery disease (hazard ratio, 1.50 [95% CI, 1.38–1.63]) and stroke (hazard ratio, 1.44 [95% CI, 1.22–1.70]). Genetically proxied blood pressure had a similar relationship with CVD in men and women. These findings provide evidence to support that even for individuals who do not have elevated blood pressure, public health interventions achieving persistent blood pressure reduction will be of considerable benefit in the primary prevention of CVD.

Risk factor control after ischemic stroke or transient ischemic attack

OBJECTIVE

We aimed to estimate the status of risk factor control after ischemic stroke or transient ischemic attack (IS/TIA), and the influence on recurrent stroke in rural communities of northeastern China.

METHODS

This population-based, prospective cohort study enrolled adults aged ≥35 years residing in rural northeastern China. We conducted cardiovascular health examinations in 2012-2015 and followed up in 2018 to record any cardiovascular event. Control of risk factors after IS/TIA was determined through a baseline survey. The Cox proportional hazard model was used to evaluate the relationship between uncontrolled risk factors and stroke recurrence.

RESULTS

Of the 10,700 participants, 575 were diagnosed with IS/TIA and were included in the analysis. At baseline, the rates of control of risk factors were as follows: fasting plasma glucose (FPG), 81.6%; not currently smoking, 65.7%; and achieving physical activity targets, 61%. Blood pressure (BP), low-density lipoprotein cholesterol (LDL-C), and body mass index (BMI) were poorly controlled (28.3%, 26.3%, and 37.4%, respectively). The rate of stroke recurrence was 12% during a median follow-up of 4.43 years. After adjusting for age, sex, ethnicity, family history of stroke, and current drinking, uncontrolled BP and not achieving physical exercise targets were associated with an increased risk of recurrence (hazard ratios: 2.081, 1.685, respectively; p < .05). Uncontrolled FPG, BMI, or LDL-C and current smoking did not significantly influence recurrent risk (p > .05).

CONCLUSIONS

Control of risk factors after IS/TIA needs to be improved in rural communities of northeastern China to prevent recurrence and thus alleviate the public health and economic burden of stroke.

Systolic Blood Pressure Trajectories After Discharge and Long-Term Clinical Outcomes of Ischemic Stroke

[Figure: see text].

Blood Pressure Level and Variability During Long-Term Prasugrel or Clopidogrel Medication After Stroke: PRASTRO-I

BACKGROUND AND PURPOSE

High blood pressure increases bleeding risk during treatment with antithrombotic medication. The association between blood pressure levels and the risk of recurrent stroke during long-term secondary stroke prevention with thienopyridines (particularly prasugrel) has not been well studied.

METHODS

This was a post hoc analysis of the randomized, double-blind, multicenter PRASTRO-I trial (Comparison of Prasugrel and Clopidogrel in Japanese Patients With Ischemic Stroke-I). Patients with noncardioembolic stroke were randomly assigned (1:1) to receive prasugrel 3.75 mg/day or clopidogrel 75 mg/day for 96 to 104 weeks. Risks of any ischemic or hemorrhagic stroke, combined ischemic events, and combined bleeding events were determined based on the mean level and visit-to-visit variability, including successive variation, of systolic blood pressure (SBP) throughout the observational period. These risks were also compared between quartiles of mean SBP level and successive variation of SBP.

RESULTS

A total of 3747 patients (age 62.1±8.5 years, 797 women), with a median average SBP level during the observational period of 132.5 mm Hg, were studied. All the risks of any stroke (146 events; hazard ratio, 1.318 [95% CI, 1.094-1.583] per 10-mm Hg increase), ischemic stroke (133 events, 1.219 [1.010-1.466]), hemorrhagic stroke (13 events, 3.247 [1.660-6.296]), ischemic events (142 events, 1.219 [1.020-1.466]), and bleeding events (47 events, 1.629 [1.172-2.261]) correlated with increasing mean SBP overall. Similarly, an increased risk of these events correlated with increasing successive variation of SBP (hazard ratio, 3.078 [95% CI, 2.220-4.225] per 10-mm Hg increase; 3.051 [2.179-4.262]; 3.276 [1.172-9.092]; 2.865 [2.042-4.011]; 2.764 [1.524-5.016], respectively). Event rates did not differ between the clopidogrel and prasugrel groups within each quartile of SBP or successive variation of SBP.

CONCLUSIONS

Both high mean SBP level and high visit-to-visit variability in SBP were significantly associated with the risk of recurrent stroke during long-term medication with either prasugrel or clopidogrel after stroke. Control of hypertension would be important regardless of the type of antiplatelet drugs. Registration: URL: https://www.clinicaltrials.jp; Unique identifier: JapicCTI-111582.

Effect of a Coordinated Community and Chronic Care Model Team Intervention vs Usual Care on Systolic Blood Pressure in Patients With Stroke or Transient Ischemic Attack: The SUCCEED Randomized Clinical Trial

IMPORTANCE

Few stroke survivors meet recommended cardiovascular goals, particularly among racial/ethnic minority populations, such as Black or Hispanic individuals, or socioeconomically disadvantaged populations.

OBJECTIVE

To determine if a chronic care model-based, community health worker (CHW), advanced practice clinician (APC; including nurse practitioners or physician assistants), and physician team intervention improves risk factor control after stroke in a safety-net setting (ie, health care setting where all individuals receive care, regardless of health insurance status or ability to pay).

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial included participants recruited from 5 hospitals serving low-income populations in Los Angeles County, California, as part of the Secondary Stroke Prevention by Uniting Community and Chronic Care Model Teams Early to End Disparities (SUCCEED) clinical trial. Inclusion criteria were age 40 years or older; experience of ischemic or hemorrhagic stroke or transient ischemic attack (TIA) no more than 90 days prior; systolic blood pressure (BP) of 130 mm Hg or greater or 120 to 130 mm Hg with history of hypertension or using hypertensive medications; and English or Spanish language proficiency. The exclusion criterion was inability to consent. Among 887 individuals screened for eligibility, 542 individuals were eligible, and 487 individuals were enrolled and randomized, stratified by stroke type (ischemic or TIA vs hemorrhagic), language (English vs Spanish), and site to usual care vs intervention in a 1:1 fashion. The study was conducted from February 2014 to September 2018, and data were analyzed from October 2018 to November 2020.

INTERVENTIONS

Participants randomized to intervention were offered a multimodal coordinated care intervention, including hypothesized core components (ie, ≥3 APC clinic visits, ≥3 CHW home visits, and Chronic Disease Self-Management Program workshops), and additional telephone visits, protocol-driven risk factor management, culturally and linguistically tailored education materials, and self-management tools. Participants randomized to the control group received usual care, which varied by site but frequently included a free BP monitor, self-management tools, and linguistically tailored information materials.

MAIN OUTCOMES AND MEASURES

The primary outcome was change in systolic BP at 12 months. Secondary outcomes were non-high density lipoprotein cholesterol, hemoglobin A1c, and C-reactive protein (CRP) levels, body mass index, antithrombotic adherence, physical activity level, diet, and smoking status at 12 months. Potential mediators assessed included access to care, health and stroke literacy, self-efficacy, perceptions of care, and BP monitor use.

RESULTS

Among 487 participants included, the mean (SD) age was 57.1 (8.9) years; 317 (65.1%) were men, and 347 participants (71.3%) were Hispanic, 87 participants (18.3%) were Black, and 30 participants (6.3%) were Asian. A total of 246 participants were randomized to usual care, and 241 participants were randomized to the intervention. Mean (SD) systolic BP improved from 143 (17) mm Hg at baseline to 133 (20) mm Hg at 12 months in the intervention group and from 146 (19) mm Hg at baseline to 137 (22) mm Hg at 12 months in the usual care group, with no significant differences in the change between groups. Compared with the control group, participants in the intervention group had greater improvements in self-reported salt intake (difference, 15.4 [95% CI, 4.4 to 26.0]; P = .004) and serum CRP level (difference in log CRP, -0.4 [95% CI, -0.7 to -0.1] mg/dL; P = .003); there were no differences in other secondary outcomes. Although 216 participants (89.6%) in the intervention group received some of the 3 core components, only 35 participants (14.5%) received the intended full dose.

CONCLUSIONS AND RELEVANCE

This randomized clinical trial of a complex multilevel, multimodal intervention did not find vascular risk factor improvements beyond that of usual care; however, further studies may consider testing the SUCCEED intervention with modifications to enhance implementation and participant engagement.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01763203.

Low blood pressure and adverse outcomes in acute stroke: HeadPoST study explanations

OBJECTIVE

As uncertainties exist over underlying causes, we aimed to define the characteristics and prognostic significance of low blood pressure (BP) early after the onset of acute stroke.

METHODS

Post hoc analyzes of the international Head Positioning in acute Stroke Trial (HeadPoST), a pragmatic cluster-crossover randomized trial of lying flat versus sitting up in stroke patients from nine countries during 2015-2016. Associations of baseline BP and death or dependency [modified Rankin scale (mRS) scores 3-6] and serious adverse events (SAEs) at 90 days were assessed in generalized linear mixed models with adjustment for multiple confounders. SBP and DBP was analysed as continuous measures fitted with a cubic spline, and as categorical measures with low (<10th percentile) and high (≥140 and ≥90 mmHg, respectively) levels compared with a normal range (≥10th percentile; 120-139 and 70-89 mmHg, respectively).

RESULTS

Among 11 083 patients (mean age 68 years, 39.9% women) with baseline BP values, 7.2 and 11.7% had low SBP (<120 mmHg) and DBP (<70 mmHg), respectively. Patients with low SBP were more likely to have preexisting cardiac and ischemic stroke and functional impairment, and to present earlier with more severe neurological impairment than other patients. Nonlinear 'J-shaped' relationships of BP and poor outcome were apparent: compared with normal SBP, those with low SBP had worse functional outcome (adjusted odds ratio 1.27, 95% confidence interval 1.02-1.58) and more SAEs, particularly cardiac events, with adjustment for potential confounders to minimize reverse causation. The findings were consistent for DBP and were stronger for ischemic rather than hemorrhagic stroke.

CONCLUSION

The prognostic significance of low BP on poor outcomes in acute stroke was not explained by reverse causality from preexisting cardiovascular disease, and propensity towards greater neurological deficits and cardiac events. These findings provide support for the hypothesis that low BP exacerbates cardiac and cerebral ischemia in acute ischemic stroke.

Fimasartan-Based Blood Pressure Control after Acute Cerebral Ischemia: The Fimasartan-Based Blood Pressure Control after Acute Cerebral Ischemia Study

Background and Purpose

Blood pressure (BP) control is strongly recommended, but BP control rate has not been well studied in patients with stroke. We evaluated the BP control rate with fimasartan-based antihypertensive therapy initiated in patients with recent cerebral ischemia.

Methods

This multicenter, prospective, single-arm trial involved 27 centers in South Korea. Key inclusion criteria were recent cerebral ischemia within 90 days and high BP [systolic blood pressure (SBP) >140 mm Hg or diastolic blood pressure (DBP) >90 mm Hg]. BP lowering was initiated with fimasartan. BP management during the follow-up was at the discretion of the responsible investigators. The primary endpoint was the target BP goal achievement rate (<140/90 mm Hg) at 24 weeks. Key secondary endpoints included achieved BP and BP changes at each visit, and clinical events (ClinicalTrials.gov Identifier: NCT03231293).

Results

Of 1,035 patients enrolled, 1,026 were included in the safety analysis, and 951 in the efficacy analysis. Their mean age was 64.1 years, 33% were female, the median time interval from onset to enrollment was 10 days, and the baseline SBP and DBP were 162.3±16.0 and 92.2±12.4 mm Hg (mean±SD). During the study period, 55.5% of patients were maintained on fimasartan monotherapy, and 44.5% received antihypertensive therapies other than fimasartan monotherapy at at least one visit. The target BP goal achievement rate at 24-week was 67.3% (48.6% at 4-week and 61.4% at 12-week). The mean BP was 139.0/81.8±18.3/11.7, 133.8/79.2±16.4/11.0, and 132.8/78.5±15.6/10.9 mm Hg at 4-, 12-, and 24-week. The treatment-emergent adverse event rate was 5.4%, including one serious adverse event.

Conclusions

Fimasartan-based BP lowering achieved the target BP in two-thirds of patients at 24 weeks, and was generally well tolerated.

Hypertension Among Hemorrhagic Stroke Patients in Northeast China: A Population-Based Study 2017-2019

BACKGROUND We aimed to profile the current epidemiology of hypertension among the survivors of hemorrhagic stroke in northeast China. MATERIAL AND METHODS Our cross-sectional study included 18 796 adults aged 40 years or older and residing in northeast China. Hemorrhagic stroke was identified according to the CT and/or MRI results. Hypertension was defined based on the Chinese hypertension guidelines. RESULTS We identified 208 patients with previous hemorrhagic stroke in this population-based study. The overall prevalence of hypertension in the studied population was 88%. Out of all the survivors of hemorrhagic stroke, 80.9% were aware of their hypertensive condition, 70.5% of the patients were in antihypertensive medications treatment, and only 12% of the patients had their blood pressure under control. Furthermore, only 17.10% of the patients who took hypertensive medications achieved appropriate blood pressure. Calcium channel blockers were more commonly used than other medications. Patients with controlled hypertension had significantly higher percentages of comorbidities when compared to those with uncontrolled hypertension. In our patient sample, the rates of stage 2 and stage 3 hypertension in the hemorrhagic stroke population were 28.8% and 15.9%, respectively, and women had a significantly higher prevalence of stage 3 hypertension when compared with men (21.3% vs. 10.0%, P=0.026). CONCLUSIONS The high prevalence of uncontrolled hypertension and high rates of blood pressure at stages 2 and 3 in patients with prior hemorrhagic stroke indicated a considerable stroke burden in northeast China. Therefore, effective and long-time management of hypertension in stroke survivors should be a priority.

Noninvasive model for predicting future ischemic strokes in patients with silent lacunar infarction using radiomics

Background

This study aimed to investigate integrating radiomics with clinical factors in cranial computed tomography (CT) to predict ischemic strokes in patients with silent lacunar infarction (SLI).

Methods

Radiomic features were extracted from baseline cranial CT images of patients with SLI. A least absolute shrinkage and selection operator (LASSO)–Cox regression analysis was used to select significant prognostic factors based on Model^C with clinical factors, Model^R with radiomic features, and Model^CR with both factors. The Kaplan–Meier method was used to compare stroke-free survival probabilities. A nomogram and a calibration curve were used for further evaluation.

Results

Radiomic signature (p < 0.01), age (p = 0.09), dyslipidemia (p = 0.03), and multiple infarctions (p = 0.02) were independently associated with future ischemic strokes. Model^CR had the best accuracy with 6-, 12-, and 18-month areas under the curve of 0.84, 0.81, and 0.79 for the training cohort and 0.79, 0.88, and 0.75 for the validation cohort, respectively. Patients with a Model^CR score < 0.17 had higher probabilities of stroke-free survival. The prognostic nomogram and calibration curves of the training and validation cohorts showed acceptable discrimination and calibration capabilities (concordance index [95% confidence interval]: 0.7864 [0.70–0.86]; 0.7140 [0.59–0.83], respectively).

Conclusions

Radiomic analysis based on baseline CT images may provide a novel approach for predicting future ischemic strokes in patients with SLI. Older patients and those with dyslipidemia or multiple infarctions are at higher risk for ischemic stroke and require close monitoring and intensive intervention.

Effect of Low Diastolic Blood Pressure to Cardiovascular Risk in Patients With Ischemic Stroke or Transient Ischemic Attacks Under Different Systolic Blood Pressure Levels

Background: In the context of recently updated strategies of pressure management, there is a paucity of evidence on the effect of diastolic blood pressure (DBP) level on adverse events among stroke patients. This study aimed to examine the effect of low DBP (<60 mmHg) under different levels of systolic blood pressure (SBP) on the risk of composite events and stroke recurrence among patients with ischemic stroke (IS) or transient ischemic attack (TIA).

Material and Methods: This study was conducted in 2,325 patients with IS or TIA. DBP values were categorized into <60, 60–70, 70–80 (reference), 80–90, and ≥90 mmHg in the main sample and were further categorized as <60 and ≥60 mmHg (reference) when patients were stratified according to SBP levels (<140, <130, and <120 mmHg). The outcomes were defined as recurrent stroke and cumulative composite events (defined as the combination of nonfatal myocardial infarction, nonfatal congestive heart failure, and death) at 1 year.

Results: During 1 year of follow-up, a total of 95 composite events and 138 stroke recurrences were identified. The patients with low DBP showed a significantly higher risk of composite events [hazard ratio (HR) = 4.86, 95% confidence interval (CI) = 2.54–8.52], especially the elderly patients (≥60 years); however, this result was not observed for stroke recurrence (HR = 0.90, 95% CI = 0.46–1.74). With the reduction of the SBP levels, the proportion of patients with low DBP increased (6.87, 12.67, and 34.46%), and the risk for composite events persisted.

Conclusions: Along with the new target levels of SBP suggested by updated criteria, there is a trend for DBP to be reduced to a harmfully low level, which was associated with an increased risk of composite events among patients with IS or TIA.

Positive Influence of Stroke Health Manager on Risk Factors Control and Medication Adherence After Ischemic Stroke

Background: From 2017, the Stroke Health Manager Training Project was carried out by the Chinese Government to strengthen health management and follow-up intervention after ischemic stroke. The aim of this study was to investigate whether after the intervention of the stroke health manager, the control of blood pressure, low-density lipoprotein cholesterol (LDL-C), glucose level, and the use of secondary prevention medications improved 3 months after discharge from our center following ischemic stroke.

Methods: The study used a history-controlled approach. Patients who received stroke health manager intervention from May 1, 2018, to March 31, 2019, were considered as the intervention group; those from May 1, 2017, to April 30, 2018, were enrolled as the control group. Stroke health manager intervention included health education, discharge advice, online WeChat public group follow-up, and clinical consultation.

Results: In total, 642 patients with ischemic stroke were enrolled in this study (277 in the control group, 365 in the intervention group). At 3 months, the blood pressure, LDL-C and glucose control in the intervention group were better than in the control group (all P < 0.05). At the same time, the overall persistence for secondary prevention medications at 3 months after discharge increased from 201/277 (72.56%) to 303/365 (83.01%, P = 0.001). The persistence for patients taking antiplatelet, hypoglycemic and statins were significantly higher in the intervention group (P < 0.05).

Conclusions: Stroke health manager intervention improved the control of blood pressure, LDL-C, glucose levels and the persistence for secondary prevention medications 3 months after discharge.

Österreichischer Blutdruckkonsens 2019

Erhöhter Blutdruck bleibt eine Hauptursache von kardiovaskulären Erkrankungen, Behinderung und frühzeitiger Sterblichkeit in Österreich, wobei die Raten an Diagnose, Behandlung und Kontrolle auch in rezenten Studien suboptimal sind. Das Management von Bluthochdruck ist eine häufige Herausforderung für Ärztinnen und Ärzte vieler Fachrichtungen. In einem Versuch, diagnostische und therapeutische Strategien zu standardisieren und letztendlich die Rate an gut kontrollierten Hypertoniker/innen zu erhöhen und dadurch kardiovaskuläre Erkrankungen zu verhindern, haben 13 österreichische medizinische Fachgesellschaften die vorhandene Evidenz zur Prävention, Diagnose, Abklärung, Therapie und Konsequenzen erhöhten Blutdrucks gesichtet. Das hier vorgestellte Ergebnis ist der erste Österreichische Blutdruckkonsens. Die Autoren und die beteiligten Fachgesellschaften sind davon überzeugt, daß es einer gemeinsamen nationalen Anstrengung bedarf, die Blutdruck-assoziierte Morbidität und Mortalität in unserem Land zu verringern.

Randomized Trial of an Intervention to Improve Blood Pressure Control in Stroke Survivors

BACKGROUND

We conducted the first-of-its kind randomized stroke trial in Africa to test whether a THRIVES (Tailored Hospital-based Risk reduction to Impede Vascular Events after Stroke) intervention improved blood pressure (BP) control among patients with stroke.

METHODS AND RESULTS

Intervention comprised a patient global risk factor control report card, personalized phone text-messaging, and educational video. Four hundred patients recruited from 4 distinct medical facilities in Nigeria, aged ≥18 years with stroke-onset within one-year, were randomized to THRIVES intervention and control group. The control group also received text messages, and both groups received modest financial incentives. The primary outcome was mean change in systolic BP (SBP) at 12 months. There were 36.5% females, 72.3% with ischemic stroke; mean age was 57.2±11.7 years; 93.5% had hypertension and mean SBP was 138.33 (23.64) mm Hg. At 12 months, there was no significant difference in SBP reduction from baseline in the THRIVES versus control group (2.32 versus 2.01 mm Hg, P=0.82). In an exploratory analysis of subjects with baseline BP >140/90 mm Hg (n=168), THRIVES showed a significant mean SBP (diastolic BP) decrease of 11.7 (7.0) mm Hg while control group showed a significant mean SBP (diastolic BP) decrease of 11.2 (7.9) mm Hg at 12 months.

CONCLUSIONS

THRIVES intervention did not significantly reduce SBP compared with controls. However, there was similar significant decrease in mean BP in both treatment arms in the subgroup with baseline hypertension. As text-messaging and a modest financial incentive were the common elements between both treatment arms, further research is required to establish whether these measures alone can improve BP control among stroke survivors.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01900756.

2018 Korean Society of Hypertension Guidelines for the management of hypertension: part II-diagnosis and treatment of hypertension

The standardized techniques of blood pressure (BP) measurement in the clinic are emphasized and it is recommended to replace the mercury sphygmomanometer by a non-mercury sphygmomanometer. Out-of-office BP measurement using home BP monitoring (HBPM) or ambulatory BP monitoring (ABPM) and even automated office BP (AOBP) are recommended to correctly measure the patient’s genuine BP. Hypertension (HTN) treatment should be individualized based on cardiovascular (CV) risk and the level of BP. Based on the recent clinical study data proving benefits of intensive BP lowering in the high risk patients, the revised guideline recommends the more intensive BP lowering in high risk patients including the elderly population. Lifestyle modifications, mostly low salt diet and weight reduction, are strongly recommended in the population with elevated BP and prehypertension and all hypertensive patients. In patients with BP higher than 160/100 mmHg or more than 20/10 mmHg above the target BP, two drugs can be prescribed in combination to maximize the antihypertensive effect and to achieve rapid BP control. Especially, single pill combination drugs have multiple benefits, including maximizing reduction of BP, minimizing adverse effects, increasing adherence, and preventing cardiovascular disease (CVD) and target organ damage.

Relation of Admission Blood Pressure to In-hospital and 90-Day Outcomes in Patients Presenting With Transient Ischemic Attack

The association between admission blood pressure (BP) and outcomes in patients with transient ischemic attack (TIA) is not well defined. Patients in the United States national Get With The Guidelines-Stroke registry with a TIA were included. Admission systolic and diastolic BP was used to compute mean arterial pressure and pulse pressure (PP). A subset of this cohort was linked to Centers for Medicare and Medicaid claims data for postdischarge outcomes. The in-hospital outcomes of interest were: mortality, not discharged home, and inability to ambulate independently at discharge. Postdischarge, 30-day and 90-day outcomes of interest were mortality, readmission for stroke, and readmission for major cardiovascular event-composite of death, cerebrovascular, or cardiovascular readmission. Among the 218,803 patients with TIA, lower admission systolic blood pressure (SBP) was associated with worse in-hospital outcomes. Compared with patients with SBP of 150 mm Hg, a lower SBP of 120 mm Hg was associated with higher risk of in-hospital death (adjusted OR = 1.79; 95% CI = 1.50 to 2.12), not being discharged home (adjusted OR = 1.31; 95% CI = 1.27 to 1.36), or inability to ambulate independently at discharge (adjusted OR = 1.27; 95% CI = 1.23 to 1.31). Similarly, among the 64,352 patients in the Centers for Medicare and Medicaid-linked cohort, an inverse association between systolic BP and postdischarge mortality (p <0.0001), and major cardiovascular event (p = 0.0001) was observed at 30-days and at 90-days postdischarge. However, there was no relation between SBP and readmission for stroke either at 30-days (p = 0.35) or at 90-days (p = 0.11). Results were largely similar for diastolic BP, mean arterial pressure, PP, and outcomes. In conclusion, in patients with a transient ischemic attack, a BP paradox was observed, with higher admission BP associated with improved in-hospital, 30-day, and 90-day postdischarge outcomes.