Antihypertensive Drugs for Secondary Prevention After Ischemic Stroke or Transient Ischemic Attack

A Systematic Review and Meta-Analysis

Giorgio B. Boncoraglio, MD; Cinzia Del Giovane, PhD; Irene Tramacere, PhD

Disclosures

Stroke. 2021;52(6):1974-1982. 

In This Article

Abstract and Introduction

Abstract

Background and Purpose: Approximately 30% of ischemic strokes occur after a previous stroke or transient ischemic attack. Arterial hypertension is one of the best established risk factors for first and recurrent stroke, both ischemic and hemorrhagic. Guidelines for the secondary prevention of ischemic stroke support the use of blood pressure (BP)–lowering drugs in most patients. However, the evidence for these recommendations comes from meta-analyses that included both ischemic and hemorrhagic stroke patients, whereas these 2 conditions differ quantitatively in several aspects. With this systematic review and meta-analysis, we aimed at summarizing the current evidence on BP-lowering drugs for secondary prevention in patients with ischemic stroke or transient ischemic attack.

Methods: We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials up to January 31, 2020. We included randomized controlled trials comparing any specific BP-lowering drug, as monotherapy or combination, with either a control or another BP-lowering drug.

Results: Eight studies that enrolled 33 774 patients with ischemic stroke or transient ischemic attack were included in the meta-analysis. Mean follow-up was 25 months (range, 3–48). Moderate-quality evidence indicated that a subsequent stroke occurred in 7.9% (ischemic in 7.4% or hemorrhagic in 0.6%) of patients taking any type of BP-lowering drug compared with 9.7% of patients taking placebo (odds ratio, 0.79 [95% CI, 0.66–0.94]; absolute risk difference, −1.9% [95% CI, −3.1% to −0.5%]). Moderate-quality evidence indicated that mortality occurred similarly in patients taking any type of BP-lowering treatment compared with placebo, with an absolute risk of 7.3% and 7.9%, respectively (odds ratio, 1.01 [95% CI, 0.92–1.10]; absolute risk difference, 0.1% [95% CI, −0.6% to 0.7%]).

Conclusions: The use of BP-lowering drugs in patients with ischemic stroke or transient ischemic attack is associated with a 1.9% risk reduction of stroke but does not affect the all-cause mortality risk.

Introduction

Stroke is the second most common cause of death worldwide, and it is expected to remain one of the leading causes of death and adult disability for the foreseeable future. Annually, 15 million people have a stroke, of which one-third will die and one-third will be permanently disabled.[1–3] Although primary prevention is most important in reduction of the burden of stroke, effective secondary prevention is also essential. About 85% of strokes are ischemic; the remaining are hemorrhagic. Approximately 30% of ischemic strokes occur in individuals with a previous stroke or transient ischemic attack (TIA), which are also at higher risk for subsequent myocardial infarction and death from vascular causes; recurrent ischemic strokes are more severe than first strokes.[4,5]

Arterial hypertension is one of the best established risk factors for first and recurrent stroke, both ischemic and hemorrhagic.[2,6] Evidences from meta-analyses of randomized controlled trials (RCTs), most of which were conducted across all stroke types, support the use of blood pressure (BP)–lowering drugs for reducing the risk of recurrent stroke.[7–11] However, given the heterogeneous causes and hemodynamic consequences of ischemic and hemorrhagic strokes, the management of BP in adults with stroke is complex, and additional high-quality evidence concerning antihypertensive use for secondary prevention by index stroke type is needed.[6,12]

With this systematic review and meta-analysis, we aimed at summarizing the current evidence on BP-lowering drugs for secondary prevention in patients qualifying with ischemic stroke or TIA and at estimating the relative efficacy and safety of various drug classes.

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