Therapeutic Strategies to Prevent First Stroke

Arterial hypertension is the most important modifiable risk factor for stroke. Major observational studies have demonstrated that blood pressure (BP) is positively and continuously associated with stroke risk and stroke mortality. Several hypertension-mediated mechanisms have been considered to play a role in the complex pathogenesis of the structural and functional alterations in cerebral vessels leading to stroke, such as vascular remodeling, inflammation, oxidative stress, and endothelial dysfunction. However, many randomized clinical trials (RCT) and meta-analyses have clearly shown that lowering BP confers significant stroke protection in hypertensive individuals. In a large meta-analysis of 25 RCTs including individuals without cardiovascular disease and 12 RCTs including patients with history of coronary artery disease but no stroke, antihypertensive treatment was associated with a 46% and 35% reduction in stroke incidence, respectively, for a given office BP reduction of 10 mmHg in systolic BP or 5 mmHg in diastolic BP. The optimal BP target for primary stroke prevention depends on the age of hypertensive subjects. According to the current guidelines, the objective in terms of BP lowering with antihypertensive medication is to attain a BP of <130/80 mmHg, which is essential for all hypertensive patients <65 years old. Antihypertensive treatment with all the major antihypertensive drug classes has shown superiority to placebo and largely similar effectiveness for the prevention of stroke. Nevertheless, some RCTs and meta-analyses have demonstrated that the reduction in the incidence of stroke was smaller in trials of β blockers as compared to the other four classes of drugs.