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July 29, 2019

Challenges to Realizing Benefits From More Intensive Blood Pressure Control for Preventing Recurrent Stroke

Author Affiliations
  • 1The George Institute for Global Health, University of New South Wales, Sydney, Australia
  • 2The George Institute for Global Health China, Peking University Health Sciences Center, Beijing, China
JAMA Neurol. Published online July 29, 2019. doi:10.1001/jamaneurol.2019.1668

Blood pressure (BP) targets below 140/90 mm Hg in high-risk patients, such as those who have had a stroke, remain a controversial topic. A pivotal meta-analysis of 61 prospective observational studies involving 1 million adults without previous cardiovascular (CV) disease showed a linear association between usual BP levels and deaths from ischemic heart disease and stroke, down to BP levels as low as 115/75 mm Hg.1 These data prompted the “lower the better” hypothesis and challenged the long-standing argument of a J-curve or U-curve association of BP levels in such patients.2 Before the pivotal Systolic Blood Pressure Intervention Trial (SPRINT),3 there had been few trials of more intensive long-term BP lowering, and they have generally failed to show a clear reduction in the risk of serious CV events,4 with the exception of stroke, for a systolic BP less than 120 mm Hg compared with less than 140 mm Hg. Although SPRINT provides some reassurance that the benefits of more intensive BP lowering outweigh the justifiable concerns over harms, such as hypotension and renal impairment, especially in elderly individuals,3,5 the study has been criticized about the generalizability of the results to patients with a history of stroke, who were purposefully excluded, and about the use of unattended automated BP measurements to titrate therapy in a highly intensive monitoring schedule.6