Blood pressure control in stroke patients

Results of numerous studies have shown that hypertension, systolic more than diastolic,1,2⇓ is a powerful independent risk factor of all strokes—hemorrhagic, ischemic, or embolic—and that lowering blood pressure strongly diminishes the risk for cerebrovascular disease. Among patients with a history of cerebrovascular disease, there is a steep, continuous relationship between any level of blood pressure and the subsequent risk for stroke.3,4⇓ In the United Kingdom TIA (UKTIA) Trial, risk for recurrent stroke increased by 28% for every incremental increase of 10 mm Hg in systolic blood pressure from 130 to 160 mm Hg.3

Despite this straightforward relationship between blood pressure and stroke, some consulting neurologists have been hesitant to monitor blood pressure or to recommend, initiate, or optimize antihypertensive therapy. This reluctance may be the result of several factors:

1. Neurologists commonly are consulted in the setting of an acute stroke and may take primary responsibility for the management of blood pressure in this situation. In a patient with such a condition, precipitously lowering arterial pressure may do more harm than good. In fact, authoritative voices such as Adams and Victor5 have warned against lowering blood pressure in this setting with statements such as, “Vasodilators may actually be harmful rather than beneficial,” and “Injections of epinephrine have been recommended as means of raising the systemic blood pressure above the usual levels.” Unfortunately, these statements and recent pilot studies6 on drug-induced hypertension for the treatment of acute stroke may have discouraged neurologist consultants from treating high blood pressure or recommending treatment in more chronic phases of cerebrovascular disease.

2. Although hypertension is a well-known, powerful risk factor for stroke, until now no solid, long-term studies have documented that good blood pressure control in a patient who has had a stroke reduces the risk for recurrent stroke. …