HT and Stroke

Surat Tanprawate, MD, FRCPTNorthern Neuroscience Center

Chiangmai University

www.neurologycoffeecup.com

Stroke

In the hand of God

CerebroVascular Accident

(CVA)

TOAST Classification

Stroke 1993

TOAST Trial of Org 10172

in Acute Stroke Treatment

HP Adams, Jr, BH Bendixen, Stroke 1993;24;35-41

TOAST Classification of Subtype of Acute Ischemic Stroke

• Large-artery atherosclerosis(emboli/thrombosis)

• Cardioembolism(high-risk/medium-risk)

• Small-vessel occlusion(lacune)

• Stroke of other determine etiology

• Stroke of undetermined etiology

TOAST, Trial of Org 10172 in Acute Stroke Treatment.

Features of TOAST Classification of Subtypes of Ischemic Stroke

HP Adams, Jr, BH Bendixen, Stroke 1993;24;35-41

Large artery atherosclerosis

Anterior VS Posterior circulation

Thrombosis VS Emboli

Lacunar Stroke

Lipohyalinosis

Microatheroma

Lacunar syndrome• Pure motor stroke/hemiparesis

• Hemiparesis or hemiplegia is noted, with hyperreflexia and Babinski sign; no involvement of any other system is observed.

• Ataxic hemiparesis

• A combination of pyramidal signs (eg, hemiparesis, hyperreflexia, Babinski sign) and cerebellar ataxia on the same side of the body. Lower extremities are typically more involved than are upper extremities. Nystagmus may be present.

• Dysarthria/clumsy hand

• Unilateral lower facial weakness with dysarthric speech is noted. On protrusion, the tongue may deviate to the side of facial weakness. A mild, ipsilateral hemiparesis usually is noted, but the arm is ataxic. Ipsilateral hyperreflexia and Babinski sign may be observed.

Lacunar syndrome

• Pure sensory stroke

• Unilateral sensory loss is observed. Although the patient may complain of weakness, no weakness is found on examination.

• Mixed sensorimotor stroke

• A combination of pyramidal signs (eg, hemiparesis, hyperreflexia, Babinski sign) is noted, as is sensory loss in the absence of any cortical signs

Risk Factors

Vascular Risk Factors

• High blood pressure

• Atril fibrillation

• Diabetes mellitus

• Carotid artery disease

• Myocardial infarction

• High cholesterol

• Hyper-homocysteinaemia

• Smoking

• Heavy alcohol use

• Physical inactivity

• obesity

Risk factors= Key

Hypertension

Diabetes

Smoking

Hyperlidemia

Alcoholic comsumption

Modifiable Risk Factors, Population Attributable Risk, and Projected Number of Strokes

Prevented

Exposed Population Relative risk

Projected attributable risk

Stroke prevented

Hypertension 56% 2.7 49% 360,000

Smoking 27% 1.5 12% 90,000

Atrial fibrillation 4% 3.6 9.4% 69,000

Heavy alcohol consumption 7% 1.7 4.7% 34,000

Based on 731,000 strokes.Goreleck PB. Stroke. 1994; 220-224.

Incidence of Various Risk Factors in Each Type of Stroke(%)

Risk factor Thrombosis Lacune Embolus

Atherosclerosis 56 37 34

Diabetes 26 28 13

Past hypertension 55 75 40

Hypertension

STROKE

HT

Systolic

Diastolic

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.

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.

Stroke death rate by categories of systolic blood pressure and diastolic blood pressure.

Hypertension: Pathophysiology, Diagnosis, and Management.1995:127–144.

Rates of Stroke mortality increase dramatically with

increasing SBP at any given level of DBP

Anti-Hypertensive Treatment

HT Treatment and Risk of Primary

Stroke

In the last 10 years or so, 3 placebo-controlled outcome trials specifically addressed the question as to whether CV risk is reversible in the elderly by anti-HT drug treatment: the

Systolic Hypertension in the Elderly Program (SHEP) conducted in America, the Systolic

Hypertension in Europe (Syst-Eur) Trial, and the Systolic Hypertension in China (Syst-China)

Trial.

Staessen JA, Gasowski J. et al. Lancet 2000; 355:865–872.

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: 827-830Neal B. MacMahon S. J Hypertens.1995; 13:1869-1873

JNC 7 Report JAMA. 2003;289:2560-2572

HT Treatment and Risk of Secondary

Stroke

Blood pressure controlDiabetes management

Lipid managementSmoking cessation

Alcohol moderationWeight reduction / physical activity

Carotid artery InterventionsAntiplatelet agents / anticoagulants

StatinsDiuretics +/- ACE inhibitors

Component of Secondary Stroke Prevention

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

PROGRESS Study

HOPE Study

-32%

Anti-Hypertensive Therapy Have Benefits

Beyond BP Control.

ARB and Stroke

Jeikei Heart Study

“The First Large-scale Intervention Trial

of an ARB in a Japanese Population”

Study Hypothesis

Treatment with valsartan-based therapy will yield additional protective benefits, compared with non-ARB therapy, beyond those attributable to BP control

JIKEI HEART Study

• 3,081 Japanese patients with hypertension, CHD and/or HF

• Valsartan added to conventional non-ARB therapy versus supplementary conventional non-ARB treatment to achieve aggressive BP goal of <130/80 mmHg alone

!"#$%&'%()*+,&-).$&/#012&3$456702+&(2&/"%08$&(2&)&9)%($":&0;&

<0=5*)702+&

Bosch et al. BMJ 2002;324:699–702

PROGRESS Collaborative Group. Lancet 2001;358:1033–41

Dahlöf et al. Lancet 2002;359:995–1003

HOPE (Ramipril versus

placebo)

32

High-risk patients

with vascular

disease or diabetes + one other CV risk

factor

PROGRESS (Perindopril versus

placebo)

28

Patients with a

history of stroke

or TIA

LIFE (Losartan versus

atenolol)

25

Patients with

hypertension

and LVH

Ris

k r

ed

ucti

on

(%

)

0

10

20

30

50

40

*With ACE inhibitors or other ARBs

• JIKEI HEART Study provides support for risk reduction seen in other trials, including:

• HOPE: high-risk patients with vascular disease or diabetes

• PROGRESS: patients with a history of stroke

• LIFE: patients with hypertension and LVH

• CHARM: patients with heart failure

• Val-HeFT: patients with heart failure

• JIKEI HEART Study demonstrated that valsartan-based therapy provides CV protection in patients with a variety of CV disorders

• Adding valsartan to conventional therapy improved outcomes versus non-ARB therapy

• Differences cannot be explained by BP alone

Results from JIKEI HEART Study Follow Other Major Trials

ASA/BP Control 2006 Recommendation

• Anti-hypertensives are recommended beyond the hyperacute period (Class I, Evidence A).

• Benefit for those with & w/o HTN (Class IIa, Evidence B)

• Target BP level and reduction are uncertain, but normal BP levels are <120/80 by JNC-7* (Class IIa, Evidence B).

*Chobanian AV et al. JAMA 2003;289:2560-71.

ASA/BP Control 2006 Recommendation

• Lifestyle modifications have been associated with BP reductions and should be included (Class IIb, Evidence C).

• Optimal drug regimen uncertain; data support diuretics and the combination of diuretics and an ACEI (Class I, Evidence A).

*Chobanian AV et al. JAMA 2003;289:2560-71.

ASA/Diabetes 2006 Recommendation• More rigorous control of HTN and

dyslipidemia should be considered in patients with DM.

• BP targets of 130/80 mm Hg (Class IIa, Evidence B). ACEIs and ARBs are recommended as first-choice medications for patients with DM (Class I, Evidence A).

Take Home Massage

HT is the most important risk

factor for stroke

TOAST Classification

ACEI and ARB have benefit beyond BP

reduction in stroke

Thank You for Your Attention