HT and Stroke

Surat Tanprawate, MD, FRCPT

Northern Neuroscience Center
Chiangmai University
www.neurologycoffeecup.com
 Stroke

In the hand of God

CerebroVascular
Accident
(CVA)
TOAST Classification

Stroke 1993
TOAST
Trial of Org 10172
in Acute Stroke
Treatment
HP Adams, Jr, BH Bendixen, Stroke 1993;24;35-41
TOAST Classification of Subtype
of Acute Ischemic Stroke

• Large-artery atherosclerosis(emboli/
thrombosis)
• Cardioembolism(high-risk/medium-risk)
• Small-vessel occlusion(lacune)
• Stroke of other determine etiology
• Stroke of undetermined etiology
TOAST, Trial of Org 10172 in Acute Stroke Treatment.
Features of TOAST Classification of
Subtypes of Ischemic Stroke

HP Adams, Jr, BH Bendixen, Stroke 1993;24;35-41

Large artery
atherosclerosis

Anterior VS
Posterior
circulation

Thrombosis
VS Emboli
Lacunar Stroke

Lipohyalinosis

Microatheroma
 Lacunar syndrome
• Pure motor stroke/hemiparesis
• Hemiparesis or hemiplegia is noted, with hyperreflexia and Babinski
sign; no involvement of any other system is observed.

• Ataxic hemiparesis
• A combination of pyramidal signs (eg, hemiparesis, hyperreflexia,
Babinski sign) and cerebellar ataxia on the same side of the body. Lower
extremities are typically more involved than are upper extremities.
Nystagmus may be present.

• Dysarthria/clumsy hand
• Unilateral lower facial weakness with dysarthric speech is noted. On
protrusion, the tongue may deviate to the side of facial weakness. A
mild, ipsilateral hemiparesis usually is noted, but the arm is ataxic.
Ipsilateral hyperreflexia and Babinski sign may be observed.
Lacunar syndrome
• Pure sensory stroke
• Unilateral sensory loss is observed. Although the
patient may complain of weakness, no weakness
is found on examination.

• Mixed sensorimotor stroke

• A combination of pyramidal signs (eg,
hemiparesis, hyperreflexia, Babinski sign) is
noted, as is sensory loss in the absence of any
cortical signs
 Risk
Factors
 Vascular Risk
Factors

• High blood pressure • High cholesterol

• Atril fibrillation • Hyper-homocysteinaemia
• Diabetes mellitus • Smoking
• Carotid artery • Heavy alcohol use
disease • Physical inactivity
• Myocardial infarction • obesity
Risk factors= Key
Hypertension
Diabetes
Smoking
Hyperlidemia
 Alcoholic
comsumption
Modifiable Risk Factors, Population Attributable
Risk, and Projected Number of Strokes
Prevented
Population Projected Stroke
Exposed Relative risk attributable risk prevented

Hypertens
56% 2.7 49% 360,000
ion

Smoking 27% 1.5 12% 90,000

Atrial
4% 3.6 9.4% 69,000
fibrillation
Heavy alcohol
consumption
7% 1.7 4.7% 34,000
Based on 731,000 strokes.
Goreleck PB. Stroke. 1994; 220-224.
 Incidence of Various Risk Factors
in Each Type of Stroke(%)
Risk factor Thrombosis Lacune Embolus

Atherosclerosis 56 37 34

Diabetes 26 28 13

Past
55 75 40
hypertension
Hypertension
HT

STROKE
Systolic

Diastolic
Stroke death rate by categories of systolic blood pressure and diastolic
blood pressure.

Hypertension: Pathophysiology, Diagnosis, and Management.1995:127–144.

Stroke death rate by categories of systolic blood pressure and diastolic
blood pressure.

Hypertension: Pathophysiology, Diagnosis, and Management.1995:127–144.

Stroke death rate by categories of systolic blood pressure and diastolic
blood pressure.

Hypertension: Pathophysiology, Diagnosis, and Management.1995:127–144.

Stroke death rate by categories of systolic blood pressure and diastolic
blood pressure.

Hypertension: Pathophysiology, Diagnosis, and Management.1995:127–144.

Stroke death rate by categories of systolic blood pressure and diastolic
blood pressure.

Hypertension: Pathophysiology, Diagnosis, and Management.1995:127–144.

 Rates of Stroke
mortality increase
dramatically with
increasing SBP at any
given level of DBP
Anti-Hypertensive
Treatment
HT Treatment and
Risk of Primary
Stroke
 10
In the last years or so, 3 placebo-
controlled outcome trials specifically addressed
the question as to whether CVrisk is reversible
in the elderly by anti-HT drug treatment: the
Systolic Hypertension in the Elderly Program
(SHEP) conducted in America, the Systolic
Hypertension in Europe (Syst-Eur) Trial, and the
Systolic Hypertension in China (Syst-China)
Trial.

Staessen JA, Gasowski J. et al. Lancet 2000; 355:865–872.

 Treatment of
Blood pressure
• Increase BP increase risk of stroke
• 5 mm Hg(DBP): ) 33% increase in stroke
• BP reduction of 5-6 mm Hg reduction
DBP(10-12 mm Hg SBP) reduce the risk of
stroke by 35-40%

The RISC Group. Lancet.1990;335: 827-830

Neal B. MacMahon S. J Hypertens.1995; 13:1869-1873
JNC 7 Report JAMA. 2003;289:2560-2572
HT Treatment and
Risk of Secondary
Stroke
Component of Secondary
Stroke Prevention
Blood pressure control
Diabetes management
Lipid management
Smoking cessation
Alcohol moderation
Weight reduction / physical activity

Carotid artery Interventions

Antiplatelet agents / anticoagulants
Statins
Diuretics +/- ACE inhibitors
Systematic review of 7 randomized trials of pharmacological blood-
pressure-lowering treatment in patients with a prior stroke or TIA

2 Large RCT
PROGRESS study
PATS study Rashid P, Leonardi-Bee J. Stroke2003; 34(11):2741–8.
PROGRESS Study
HOPE Study

-32%
 Anti-Hypertensive
Therapy Have Benefits
Beyond BP Control.
ARB and Stroke
Jeikei Heart
Study
“The First Large-scale
Intervention Trial
of an ARB in a Japanese
Population”
Study Hypothesis

Treatment with valsartan-based

therapy will yield additional
protective benefits, compared
with non-ARB therapy, beyond
those attributable to BP control
 JIKEI HEART
Study
• 3,081 Japanese patients with hypertension,
CHD and/or HF
• Valsartan added to conventional non-ARB
therapy versus supplementary conventional
non-ARB treatment to achieve aggressive
BP goal of <130/80 mmHg alone
 !"#$%&'%()*+,&-).$&/#012&3$456702+&(2&/"%08$&(2&)&9)%($":&0;&
<0=5*)702+&

HOPE PROGRESS LIFE

(Ramipril versus (Perindopril versus (Losartan versus
placebo) placebo) atenolol)

32 28 25
10
Risk reduction (%)

20

30
High-risk patients Patients with a Patients with
with vascular history of stroke hypertension
40 disease or diabetes or TIA and LVH
+ one other CV risk
factor
50
Bosch et al. BMJ 2002;324:699–702
PROGRESS Collaborative Group. Lancet 2001;358:1033–41
*With ACE inhibitors or other ARBs
Dahlöf et al. Lancet 2002;359:995–1003
Results from JIKEI HEART Study Follow Other Major Trials

• JIKEI HEART Study provides support for risk reduction seen in

other trials, including:

• HOPE: high-risk patients with vascular disease or diabetes

• PROGRESS: patients with a history of stroke

• LIFE: patients with hypertension and LVH

• CHARM: patients with heart failure

• Val-HeFT: patients with heart failure

• JIKEI HEART Study demonstrated that valsartan-based therapy

provides CV protection in patients with a variety of CV disorders

• Adding valsartan to conventional therapy improved outcomes

versus non-ARB therapy

• Differences cannot be explained by BP alone

ASA/BP Control 2006
Recommendation
• Anti-hypertensives are recommended beyond
the hyperacute period (Class I, Evidence A).
• Benefit for those with & w/o HTN (Class IIa,
Evidence B)
• Target BP level and reduction are uncertain, but
normal BP levels are <120/80 by JNC-7*
(Class IIa, Evidence B).
*Chobanian AV et al. JAMA 2003;289:2560-71.
ASA/BP Control 2006
Recommendation

• Lifestyle modifications have been associated with

BP reductions and should be included (Class IIb,
Evidence C).
• Optimal drug regimen uncertain; data support
diuretics and the combination of diuretics and an
ACEI (Class I, Evidence A).

*Chobanian AV et al. JAMA 2003;289:2560-71.

ASA/Diabetes 2006
Recommendation
• More rigorous control of HTN and
dyslipidemia should be considered in
patients with DM.
• BP targets of 130/80 mm Hg (Class IIa,
Evidence B). ACEIs and ARBs are
recommended as first-choice medications
for patients with DM (Class I, Evidence A).
Take Home
Massage
 TOAST
Classification

HT is the most ACEI and ARB

important risk
factor for stroke have benefit
beyond BP
reduction in
stroke
Thank You for Your
Attention