One Year After Stroke Hypertension Not Well Controlled in Most Patients

Daniel M. Keller, PhD

October 28, 2010

October 28, 2010 (Seoul, South Korea) — One year after having a stroke, most patients in a moderately large Danish cohort were hypertensive. Their compliance with medication regimens appeared to be excellent, suggesting an underuse of diuretics and combination therapies, the study authors suggest.

The study was presented here at the 7th World Stroke Congress.

Between April 2004 and September 2007, 1306 patients admitted to any of 3 hospitals in Copenhagen, Denmark, with an acute stroke or first or recurrent transient ischemic attack (TIA) were included in a consecutive cohort. Researches recorded antihypertensive treatment before the stroke, at hospital discharge, and 1 year later.

In this follow-up study of 421 patients from the original cohort, 75% of participants had had an ischemic stroke, 20% a TIA, and 5% a hemorrhagic stroke. Their median age was 71 years (range, 61 – 80 years), 52% were men, 13% had a diagnosis of diabetes at discharge, 39% were current smokers, and 52% had a body mass index (BMI) greater than 25 kg/m2.

Lead study author Nete Hornnes, PhD, of the Clinical Research Centre at Hvidovre Hospital in Hvidovre, Denmark, said at 2 to 3 days after being admitted to the hospital for their stroke, only 8% of this follow-up cohort had been normotensive, with blood pressure (BP) less than 120/80 mm Hg.

At that time, prehypertension existed in 22% (defined as BP ≥120/80 mm Hg and <140/90 mm Hg). Most (70%) had stage 1 (BP ≥140/90 and <160/100 mm Hg, 30%) or stage 2 (BP ≥160/100 mm Hg, 40%) hypertension, according to definitions used in the US Joint National Committee's seventh report.

On admission for stroke, 45% of patients had been undergoing antihypertensive therapy and were receiving an average of 1.7 antihypertensive drugs. At discharge, 61% were receiving treatment and were taking a mean of 1.6 drugs, and on follow-up, 67% were treated, with a mean of 1.7 drugs.

"Treatment with diuretics is often underused in patients with hypertension, and we found that of those treated, 53% of patients had a diuretic on admission, 47% at discharge, and at follow-up half the patients were treated with diuretics," Dr. Hornnes said.

When surveyed, 99% of patients reported at least 80% compliance with diuretic use in the previous 2 weeks, and 83% reported total compliance with diuretic use. For all antihypertensive medications, 98% of the patients declared 80% compliance, and 93% declared 100% compliance.

BP measurements at 1-year follow-up were made with the patient in a sitting position using both arms with a digital BP monitor after the patient was at rest for 5 minutes. Three readings at 10-minute intervals were made using the arm with the highest systolic measurements. At follow-up only 12% had no hypertension.

Prehypertension existed in 29%, 31% had stage 1 hypertension, and 28% had stage 2 hypertension. "So more than half of the participants were hypertensive 1 year after stroke," Dr. Hornnes reported. "No matter whether they were untreated or [taking] one or more drugs, more than half of the patients had hypertension."

Table 1. Percentage of Patients with Hypertension (HT) by Number of Drugs

No. of Drugs No HT Pre-HT Stage 1 HT Stage 2 HT
0 15 31 33 21
1 7 27 35 31
2 13 33 24 30
≥3 10 18 36 36

 

As the number of risk factors increased, so did the proportion of patients with stage 1 or stage 2 hypertension. The increase was most notable for stage 2 hypertension. The 7 risk factors that the researchers considered were age of 75 years or older, BMI of 25 kg/m2 or higher, excessive alcohol consumption, hypercholesterolemia, diabetes, inactivity, and current smoking.

"You see there is a nice linear relationship between the number of risk factors and the proportion of patients with stage 2 hypertension," Dr. Hornnes said. From a regression analysis, the researchers found that systolic BP on day 2 or 3 after stroke was a significant predictor of systolic BP on follow-up, and so were age and smoking.

Table 2. Hypertension (HT) by Number of Risk Factors

No. of Risk Factors Stage 1 HT Stage 2 HT
0 25 7
1 35 14
2 34 25
≥3 30 36

 

Dr. Hornnes concluded that most patients were hypertensive 1 year after stroke despite good compliance with antihypertensive medication regimens.

"More intensive antihypertensive treatment, including a diuretic, is needed in order to reduce these patients' risk of further cardiovascular complications, and it's important to consider the whole risk factor profile of the patient," she advised.

Verifying Compliance Data

Session moderator Hans-Christoph Diener, MD, PhD, professor and chairman of the Department of Neurology at the University of Duisberg-Essen in Germany, challenged the compliance data, as he said, for the simple reason that "if you simply ask patients whether they took medications, the compliance is always very high."

He said he recently performed a series of studies in different diseases to check the patients' reports compared with prescription refill data from insurance companies. In those studies he said there was a big discrepancy. "Ninety percent of the people claimed to be compliant, but looking at the refills it was clear that only 50% of the patients were compliant," he said.

Dr. Hornnes said in her study, nurses assisted patients in taking their pills, and there were pill containers to account for use, so although the compliance may not have been as high as the reports indicated, she said she was confident that compliance was quite high.

Dr. Diener said a positive confounder in the study was that nurses came to take BP measurements, and just knowing that would probably induce patients to take their medications.

And he said about BP control in general, "I think on a global level it's a nightmare that we are still not able really to control blood pressure even in healthcare systems as sophisticated as in Denmark. In Germany, it's exactly the same problem."

Dr. Hornnes has disclosed no relevant financial relationships. Dr. Diener disclosed receiving consulting fees and lecture fees from Boehringer Ingelheim, Abbott, AstraZeneca, Bayer, Bristol-Myers Squibb, CoAxia, D-Pharm, Fresenius, Glaxo-SmithKline, Janssen Cilag, Merck Sharp and Dohme, MindFrame, Neurobiological Technologies, Novartis, Novo-Nordisk, Paion, Parke-Davis, Pfizer, Sanofi-Aventis, Sankyo, Servier, Solvay, Thrombogenics, Wyeth, and Yamaguchi and grant support from Boehringer Ingelheim, AstraZeneca, GlaxoSmithKline, Novartis, Janssen-Cilag, and Sanofi-Aventis.

7th World Stroke Congress (WSC): Abstract FC60004. Presented October 15, 2010.

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