Preventing Stroke Recurrence: How Best to Control Hypertension?

In the Perindopril Protection against Recurrent Stroke Study (PROGRESS, JW Cardiol Dec 14 2001), lowering blood pressure with an ACE inhibitor plus a diuretic after a stroke reduced the rate of recurrent stroke. The Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS) was an industry-sponsored, international study of strategies to reduce the risk for recurrent stroke. In the antihypertensive arm of the trial, 20,332 patients were randomized to receive telmisartan (an angiotensin-receptor blocker) or placebo within 120 days after experiencing an ischemic stroke; additional blood-pressure control agents were allowed at investigators’ discretion. Mean patient age was 66, and about one third were women. At baseline, mean systolic blood pressure was 144 mm Hg, and about three quarters of the patients had histories of hypertension.

As expected, the average systolic blood pressure was lower in the telmisartan group than in the placebo group, by 5.4 mm Hg at 1 month and 4.0 mm Hg at 1 year. At a mean follow-up of 30 months, a first recurrent stroke (the primary outcome) occurred in 8.7% of the telmisartan group and 9.2% of the placebo group (hazard ratio, 0.95; P=0.23). Cardiovascular events occurred in 13.5% of the telmisartan group and 14.4% of the placebo group. Mortality was similar in the two groups. Over the course of the study, more patients in the telmisartan group than in the placebo group discontinued study medications, primarily because of hypotensive symptoms. No interaction was found with the results of the antiplatelet arm of the same trial (JW Cardiol Aug 27 2008).