Tokyo, Japan—Is standard blood pressure (BP) control enough to reduce risk of recurrent stroke, or is more intense therapy required?

That was the question addressed in a recent randomized clinical trial and meta-analysis published in JAMA Neurology. The report notes that intensive BP control to less than 130/80 mmHg is recommended for secondary stroke prevention.

Researchers from Tokyo Women’s Medical University and colleagues conducted a study involving 1,263 patients with a history of stroke, determining that intensive BP control to less than 120/80 mmHg tended to reduce stroke recurrence compared with standard BP control of less than 140/90 mm Hg.

The study adds that when those results were pooled with findings of prior trials of intensive BP control for secondary stroke prevention in an updated meta-analysis, intensive BP treatment significantly reduced stroke recurrence by 22%.

Background information in the report notes that the Systolic Blood Pressure Intervention Trial (SPRINT) demonstrated that a systolic BP target less than 120 mmHg was superior to less than 140 mmHg for preventing vascular events. Researchers point out, however, that the trial excluded patients with prior stroke and offered no guidance on the ideal BP target for secondary stroke prevention. That’s why they followed up with their study.

Patients with previous stroke were enrolled between October 20, 2010, and December 7, 2016, from 140 hospitals in Japan. Subsequently, for an updated meta-analysis, PubMed and the Cochrane Central Library database were searched through September 30, 2018, for related topics.

Participants, 69.4% male with a mean age of 67.2, were randomized 1:1 to BP control to less than 140/90 mmHg (standard treatment) or to less than 120/80 mmHg (intensive treatment). Stroke recurrence was defined as the primary outcome.

With a mean BP at baseline of 145.4/83.6 mmHg throughout the overall follow-up period, the mean BP was 133.2/77.7 (95% CI, 132.5-133.8/77.1-78.4) mmHg in the standard group and 126.7/77.4 (95% CI, 125.9-127.2/73.8-75.0) mmHg in the intensive group, according to the researchers, who advise that the trial was ended early.

The study reports that 91 first recurrent strokes occurred and that nonsignificant rate reductions were seen for recurrent stroke in the intensive group compared with the standard group (hazard ratio, 0.73; 95% CI, 0.49-1.11; P = .15).

When this finding was pooled in three previous relevant randomized, controlled trials in a meta-analysis, the risk ratio favored intensive BP control (relative risk, 0.78; 95% CI, 0.64-0.96; P = .02; absolute risk difference, -1.5%; 95% CI, -2.6% to -0.4%; number needed to treat, 67; 95% CI, 39-250).

“Intensive BP lowering tended to reduce stroke recurrence,” study authors note. “The updated meta-analysis supports a target BP less than 130/80 mm Hg in secondary stroke prevention.”

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