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White-matter ischemic lesions (WMLs) are common imaging findings in older adults and in patients with vascular risk factors. These lesions are thought to represent small vessel disease, and accumulation of WMLs has been associated with cognitive impairment and gait disorders.
Authors from the SPRINT-MIND study group conducted a substudy within a large clinical trial that compared two different blood pressure (BP) goals, either systolic BP (SBP) <120 mm Hg or SBP <140 mm Hg. The objective of the substudy was to evaluate the effect of different BP treatments on the progression of WMLs of presumed ischemic origin. Effect on brain volume was a secondary goal.
Of 670 participants recruited (mean age, 67; 40% women), 449 had follow-up MRI scans. Median follow-up was 4 years and median score on the Montreal Cognitive Assessment was 24. At the end of the on-study BP treatment period, mean SBP was 121 mm Hg in the intensive group versus 135 mm Hg in the standard group. During the study, WML volume increased less in the intensive group (from 4.57 cm3 to 5.49 cm3) than in the standard group (from 4.40 cm3 to 5.85 cm3; between-group difference, 0.54 cm3). Mean total brain volume decreased slightly more in the intensive group (from 1135 cm3 to 1104 cm3) than in the standard group (from 1134 cm3 to 1107 cm3; between-group difference, 3.7 cm3).
Nasrallah IM et al. Association of intensive vs standard blood pressure control with cerebral white matter lesions. JAMA 2019 Aug 13; 322:524. (https://doi.org/10.1001/jama.2019.10551)
Prabhakaran S.Blood pressure, brain volume and white matter hyperintensities, and dementia risk. JAMA 2019 Aug 13; 322:512. (https://doi.org/10.1001/jama.2019.10849)
Comment
In this study, intensive BP control decreased the rate of progression of WML over a 4-year period, with no major difference in brain volume. Neurologists should support achievement of lower BP targets. Participants were enrolled at a relatively advanced age; it would be of interest to know if intensive BP control has greater benefits in midlife. Also, SPRINT excluded patients with diabetes mellitus and those with previous strokes. These two groups have a substantial burden of ischemic white-matter disease, and the effect of intensive BP treatment on brain lesions in these groups should be explored further.