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Does lowering blood pressure prevent recurrent stroke?

Question In patients with a history of stroke or transient ischaemic attack, can further stroke be prevented by lowering blood pressure, even when it is not elevated? Commentary Rationale for the trial About one in five stroke survivors suffer another stroke in the five years after the initial incident. 1 Blood pressure is related in a continuous manner to the risk of an initial stroke, but many strokes occur in individuals with normal blood pressure. However, there are fewer data on the relationship between blood pressure and recurrent stroke. Systematic reviews of randomised trials of blood-pressure-lowering drugs in patients with hypertension who do not have clinical evidence of cerebrovascular disease show that sustained lowering of blood pressure reduces risk for stroke by about a third. 2 Fewer data are available on the effect of lowering blood pressure in individuals with a history of cerebrovascular disease. Trial methods Importantly, the trial tested the effect of treatment in patients with a wide range of entry blood pressures, including those who were normotensive, defined as systolic blood pressure less than 160 mmHg and diastolic blood pressure less than 90 mmHg. Because of this, the results of the trial are more generalisable than if it only included patients with hypertension. The design also allowed for clinician choice for single or combination therapy. The predefined outcomes were adjudicated by an expert committee and were deemed to be clinically relevant. Randomisation was appropriate with stratification for known prognostic factors. The sample-size estimates were robust and based on worthwhile and plausible differences in stroke rates. Analysis was on an intention-to-treat basis and subgroup analyses were pre-specified. Both absolute benefits as well as relative-risk reductions were reported. The study establishes the value of blood pressure lowering to prevent recurrent stroke (both ischaemic and haemor-rhagic). In particular, it demonstrates the role of blood pressure lowering for secondary prevention of stroke in normotensive patients. PROGRESS is the first study to show benefit for Asian as well as white populations. The trial also showed that blood pressure lowering can prevent coronary events in patients with previous stroke, and that blood pressure lowering was safe at least two weeks after a stroke or transient ischaemic attack. Implications for clinical practice In patients who have just had a stroke (irrespective of their age, whether they are hypertensive or normotensive and whether they have sustained ischaemic or haemorrhagic stroke), after two weeks, or when …