HT and Stroke
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HT and Stroke
Surat Tanprawate, MD, FRCPTNorthern Neuroscience Center
Chiangmai University
www.neurologycoffeecup.com
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Stroke
In the hand of God
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CerebroVascular Accident
(CVA)
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TOAST Classification
Stroke 1993
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TOAST Trial of Org 10172
in Acute Stroke Treatment
HP Adams, Jr, BH Bendixen, Stroke 1993;24;35-41
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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.
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Features of TOAST Classification of Subtypes of Ischemic Stroke
HP Adams, Jr, BH Bendixen, Stroke 1993;24;35-41
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Large artery atherosclerosis
Anterior VS Posterior circulation
Thrombosis VS Emboli
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Lacunar Stroke
Lipohyalinosis
Microatheroma
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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.
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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
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Risk Factors
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Vascular Risk Factors
• High blood pressure
• Atril fibrillation
• Diabetes mellitus
• Carotid artery disease
• Myocardial infarction
• High cholesterol
• Hyper-homocysteinaemia
• Smoking
• Heavy alcohol use
• Physical inactivity
• obesity
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Risk factors= Key
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Hypertension
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Diabetes
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Smoking
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Hyperlidemia
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Alcoholic comsumption
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Modifiable Risk Factors, Population Attributable Risk, and Projected Number of Strokes
Prevented
Exposed Population Relative risk
Projected attributable risk
Stroke prevented
Hypertension 56% 2.7 49% 360,000
Smoking 27% 1.5 12% 90,000
Atrial fibrillation 4% 3.6 9.4% 69,000
Heavy alcohol consumption 7% 1.7 4.7% 34,000
Based on 731,000 strokes.Goreleck PB. Stroke. 1994; 220-224.
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Incidence of Various Risk Factors in Each Type of Stroke(%)
Risk factor Thrombosis Lacune Embolus
Atherosclerosis 56 37 34
Diabetes 26 28 13
Past hypertension 55 75 40
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Hypertension
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STROKE
HT
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Systolic
Diastolic
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Stroke death rate by categories of systolic blood pressure and diastolic blood pressure.
Hypertension: Pathophysiology, Diagnosis, and Management.1995:127–144.
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Stroke death rate by categories of systolic blood pressure and diastolic blood pressure.
Hypertension: Pathophysiology, Diagnosis, and Management.1995:127–144.
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Stroke death rate by categories of systolic blood pressure and diastolic blood pressure.
Hypertension: Pathophysiology, Diagnosis, and Management.1995:127–144.
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Stroke death rate by categories of systolic blood pressure and diastolic blood pressure.
Hypertension: Pathophysiology, Diagnosis, and Management.1995:127–144.
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Stroke death rate by categories of systolic blood pressure and diastolic blood pressure.
Hypertension: Pathophysiology, Diagnosis, and Management.1995:127–144.
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Rates of Stroke mortality increase dramatically with
increasing SBP at any given level of DBP
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Anti-Hypertensive Treatment
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HT Treatment and Risk of Primary
Stroke
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In the last 10 years or so, 3 placebo-controlled outcome trials specifically addressed the question as to whether CV risk 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.
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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: 827-830Neal B. MacMahon S. J Hypertens.1995; 13:1869-1873
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JNC 7 Report JAMA. 2003;289:2560-2572
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HT Treatment and Risk of Secondary
Stroke
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Blood pressure controlDiabetes management
Lipid managementSmoking cessation
Alcohol moderationWeight reduction / physical activity
Carotid artery InterventionsAntiplatelet agents / anticoagulants
StatinsDiuretics +/- ACE inhibitors
Component of Secondary Stroke Prevention
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Systematic review of 7 randomized trials of pharmacological blood-pressure-lowering treatment in patients with a prior stroke or TIA
Rashid P, Leonardi-Bee J. Stroke2003; 34(11):2741–8.
2 Large RCTPROGRESS studyPATS study
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PROGRESS Study
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HOPE Study
-32%
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Anti-Hypertensive Therapy Have Benefits
Beyond BP Control.
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ARB and Stroke
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Jeikei Heart Study
“The First Large-scale Intervention Trial
of an ARB in a Japanese Population”
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Study Hypothesis
Treatment with valsartan-based therapy will yield additional protective benefits, compared with non-ARB therapy, beyond those attributable to BP control
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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
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!"#$%&'%()*+,&-).$&/#012&3$456702+&(2&/"%08$&(2&)&9)%($":&0;&
<0=5*)702+&
Bosch et al. BMJ 2002;324:699–702
PROGRESS Collaborative Group. Lancet 2001;358:1033–41
Dahlöf et al. Lancet 2002;359:995–1003
HOPE (Ramipril versus
placebo)
32
High-risk patients
with vascular
disease or diabetes + one other CV risk
factor
PROGRESS (Perindopril versus
placebo)
28
Patients with a
history of stroke
or TIA
LIFE (Losartan versus
atenolol)
25
Patients with
hypertension
and LVH
Ris
k r
ed
ucti
on
(%
)
0
10
20
30
50
40
*With ACE inhibitors or other ARBs
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• 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
Results from JIKEI HEART Study Follow Other Major Trials
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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.
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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.
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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).
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Take Home Massage
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HT is the most important risk
factor for stroke
TOAST Classification
ACEI and ARB have benefit beyond BP
reduction in stroke
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Thank You for Your Attention