Outline antihypertensives antilipid agents antithrombotics
other pharmacologic approaches
Slide 12
Two phases of stroke treatment acute stroke secondary
prevention
Slide 13
Two phases of stroke treatment acute stroke secondary
prevention weeks to months
Slide 14
Hypertension and stroke
Slide 15
Who should be treated? All patients after stroke? All
hypertensive patients after stroke? What about patients with non-
atherosclerotic causes of stroke? Could some patients be harmed by
lowering blood pressure?
Slide 16
Causes of cerebral infarction small vessel disease atrial
fibrillation cryptogenic large vessel disease other
Slide 17
Who should be treated? All patients after stroke? Across
numerous randomized studies, there has not been any subset of
patients that does not clearly benefit from blood pressure
reduction in stroke prevention. Yes
Slide 18
Who should be treated? All hypertensive patients after stroke?
Stroke prevention occurs with treatment in patients regardless of
baseline blood pressure.
Slide 19
Who should be treated? What about non-atherosclerotic causes of
stroke? There is an argument that patients who are normotensive
(120/70) and have specific causes of stroke such as atrial
fibrillation, DVT with PFO, endocarditis, or hypercoagulable states
may not benefit from treatment. This question is not
well-studied.
Slide 20
Who should be treated? Who might be harmed? large vessel
disease concern for cerebral hypoperfusion
Slide 21
Who should be treated? Who might be harmed? For patients with
large vessel stenosis >50% (especially >70%), there is a risk
of recurrent stroke with aggressive treatment. However, some
studies suggest benefit with long-term, stepwise aggressive
lowering of blood pressure.
Slide 22
How much to lower?
Slide 23
How much to lower? Some support for all these answers!! the
lower, the less risk of stroke
Slide 24
Which agents to choose? Diuretics Beta blockers ACE inhibitors
Angiotension receptor blockers Calcium channel blockers Alpha
blockers
Slide 25
Which agents to choose? Diuretics Beta blockers ACE inhibitors
Angiotension receptor blockers Calcium channel blockers Alpha
blockers Ultimately, achieving reduction in blood pressure is
likely more important than specific agent required.
Slide 26
Which agents to choose? Diuretics Beta blockers ACE inhibitors
Angiotension receptor blockers Calcium channel blockers Alpha
blockers All these agents have safety/efficacy after stroke.
Slide 27
Which agents to choose? Diuretics Beta blockers ACE inhibitors
Angiotension receptor blockers Calcium channel blockers Alpha
blockers Though traditionally first-line agents, in one trial HCTZ
was inferior to CaCB; indapamide and chlorthalidone may have better
support.
Slide 28
Which agents to choose? Diuretics Beta blockers ACE inhibitors
Angiotension receptor blockers Calcium channel blockers Alpha
blockers Concerns about blood pressure variability and central vs
peripheral effects make beta blockers not the initial preferred
agents after stroke.
Slide 29
Which agents to choose? Diuretics Beta blockers ACE inhibitors
Angiotension receptor blockers Calcium channel blockers Alpha
blockers These agents may increase the risk of stroke, despite
being effective in lowering blood pressure.
Slide 30
Which agents to choose? Diuretics Beta blockers ACE inhibitors
Angiotension receptor blockers Calcium channel blockers Alpha
blockers Ultimately, achieving reduction in blood pressure is
likely more important than specific agent required.
Slide 31
Antilipid therapies
Slide 32
Cholesterol and stroke Relationship between high cholesterol
(high LDL) and stroke is less strong than for coronary heart
disease Low cholesterol has been associated with intracerebral
hemorrhage However, similar mechanism from CAD strongly implied for
many causes of stroke, and similar benefit expected
Slide 33
Trial X stroke (vascular event) hemorrhage death treatment A
treatment B 15% 10% 5% 10% 10% 10% patients enrolled
Reasons to avoid high-intensity Characteristics predisposing
individuals to statin adverse effects include, but are not limited
to: Multiple or serious comorbidities, including impaired renal or
hepatic function. History of previous statin intolerance or muscle
disorders. Unexplained ALT elevations >3 times ULN. Patient
characteristics or concomitant use of drugs affecting statin
metabolism. >75 years of age. Additional characteristics that
may modify the decision to use higher statin intensities may
include, but are not limited to: History of hemorrhagic stroke.
Asian ancestry.
Slide 38
What about other agents? Niacin-ER did not lower risk of
cardiovascular events compared with placebo though it is effective
in increasing HDL and lowering triglycerides Ezetimibe has not been
shown to have any clinical benefit though it can lower LDL Omega-3
fatty acids have not been shown to benefit in stroke
prevention