Professional Documents
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Outline of my talk
Introduction to stroke risk factors HT and stroke
BP target Medication choice Role of RAS inhibitor Combination therapy
Public health statistic A.D. 2005 Third cause of death Prevalence Thai stroke: 1,850/100,000
Johnston et al Lancet Neurol 2009
Others
Since 1948
Stroke. 1991;22:312-318
Systolic
Diastolic
Stroke death rate by categories of systolic blood pressure and diastolic blood pressure.
Stroke death rate by categories of systolic blood pressure and diastolic blood pressure.
Stroke death rate by categories of systolic blood pressure and diastolic blood pressure.
stroke by 35-40%
The RISC Group. Lancet.1990;335: 827830 Neal B. MacMahon S. J Hypertens.1995; 13:18691873
Systematic review of 7 randomized trials of pharmacological bloodpressure-lowering treatment in patients with a prior stroke or TIA
BP target
Drug choice
In a meta-analysis of 23 randomized
trials with stroke outcomes, antihypertensive drug treatment reduced risk of stroke by 32% (95% CI, 24% to 39%; P0.004) in comparison with no drug treatment
ASA/AHA guideline
An absolute target BP level and reduction are uncertain and should be individualized, but benefit has been associated with an average reduction of approximately
10/5 mm Hg, and normal BP levels have been defined as 120/80 mm Hg by JNC 7
(Class IIa; Level B)
The choice of specific drugs and targets should be individualized on the basis of pharmacological properties,
mechanism of action, and consideration of specific patient characteristics for which specific agents are probably indicated (eg, extracranial cerebrovascular occlusive disease, renal impairment, cardiac disease, and diabetes) (Class IIa; Level B). (New recommendation)
Stroke 2011;42;227-276
ACEI
ARB
HOPE Study
-32%
Ramipril vs Placebo
Cardiovascular morbidity and mortality in patients with diabetes in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE)
LIFE study: Losartan vs Atenolol 9,193 hypertensives for mean 4.8 years Blood pressure reduction (SBP/DBP mmHg) was 30/17 and 29/17 in the Losartan and Atenolol arms, respectively
1.4
Adjusted hazard ratio (95% CI) 1.2 1.0 0.8 0.6
Favours atenolol
Favours losartan Primary composite endpoint Cardiovascular mortality Stroke Myocardial infarction
Dahlf et al. Lancet 2002;359:9951003
PROGRESS Study
Progress study
Perindopril vs Placebo
ProFess study
Telmisartan vs Placebo
MOSES study
Candesartan vs Nitrendipine
ONTARGET study
Telmisartan vs Ramipril
In Reality
RAS blockade has clearly benefit beyond BP reduction for preventing stroke
ARB needs more clinical trial for proving clinical effectiveness over ACEI
ARB is less side effect than ACEI
Real situation