PracticeUpdate Neurology June 2019

CONFERENCE COVERAGE 20

130/80mmHg Identified as Likely Best Target for Repeat Stroke Prevention Intensive blood pressure control particularly important for prevention of hemorrhagic stroke. M aintainingabloodpressureunder 130/80mmHg may help reduce the risk of having a repeat stroke, according to a randomized controlled less than 120/80 mmHg. The primary endpoint was the cumulative incidence of first recurrent stroke, including ischemic stroke and intracerebral hemorrhage.

trial and meta-analysis. “Blood pressure lowering [is] effective for secondary stroke prevention, but the optimum blood pressure has not been determined,” presenter Kazuo Kitagawa, MD, PhD, of Tokyo Women’s Medical University in Japan told Elsevier’s PracticeUpdate . For the RESPECT study, patients in Japan who had a recent, CT- or MRI-defined symptomatic ischemic or hemorrhagic stroke were randomized in an open-label design to intensive blood pressure control of less than 140/90 mmHg or intensive blood pressure control of

Patients were recruited between October 2010 and December 2015 in a 1:1 design, with the intention of recruiting 2000 patients. The trial was stopped, how- ever, on December 31, 2016 after enrollment of 1263 patients, due to cessation of funding. Of these patients, 630 in the standard-treatment group and 633 in the intensive-treatment group were followed up for a mean of 3.9 (standard deviation [SD] 1.5) years. Patients’ mean age was 67 (SD 8.8) years. After 1 year, mean blood pressure was 132.0/77.5 mmHg (95% con- fidence interval 130.9–133.0/76.6–78.3) in the standard target group and 123.7/72.8 mmHg (95% CI 122.6– 124.8/72.0–73.7) in the intensive target group. Overall, 91 first recurrent strokes occurred. The hazard ratio for cumulative incidence of recurrent stroke with intensive versus standard blood pressure treatment was 0.73 (95% CI0.49–1.11; P = .143). While the hazard ratio in the standard versus intensive blood pressure groups was not significant, at 0.91 (95% CI 0.59– 1.42; P = .686), for ischemic stroke, it was significant, at 0.09 (95% CI 0.01–0.70; P = .021), for intracerebral hemorrhage. In an updated meta-analysis of randomized trials pre- sented by the study authors that comprised 2454 patients, including the patients from RESPECT, the hazard ratio for the cumulative incidence of recurrent stroke with intensive versus standard blood pressure treatment was 0.78 (95% CI (0.64–0.96; P = .016). “Differences in blood pressure between [the] two groups was 8 mmHg, smaller than expected, and early termination could explain why [the difference in stroke outcomes between the two groups] did not reach sta- tistical significance,” said Dr. Kitagawa. “Nevertheless, when the findings of the RESPECT study were pooled with previous randomized controlled trials, intensive blood pressure treatment was shown to be [effective] for secondary stroke prevention, compared with stand- ard treatment. This is the most important finding. … After we published our results and updated meta-anal- ysis, blood pressure control less than 130/80 mmHg would be strongly recommended for secondary stroke prevention, as Grade A.” “Although the event of intracerebral hemorrhage was secondary outcome,” he continued, “[a] marked differ- ence in rate of intracerebral hemorrhage was observed between two groups (hazard radio 0.09). Therefore, we would recommend that patients [at] high risk of intrac- erebral hemorrhage receive intensive blood pressure treatment.” www.practiceupdate.com/c/79848

" …we would recommend that patients [at] high risk of intracerebral hemorrhage receive intensive blood pressure treatment. "

© AHA/Todd Buchanan 2019

PRACTICEUPDATE NEUROLOGY