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Blood pressure-lowering for secondary prevention of stroke: ACE inhibition is not the key.

The questions that need to be addressed in this debate are 3-fold. First, do antihypertensive agents, including angiotensin-converting enzyme (ACE) inhibitors, prevent recurrent stroke and other vascular events? Second, is this effect dependent on their blood pressure (BP)–lowering properties? And last, are potentially beneficial non-BP effects limited to ACE inhibitors? The answers are straightforward: antihypertensive drugs do prevent further vascular events; the effect is dependent on the degree to which BP is lowered; and most antihypertensive drug classes, not just ACE inhibitors, exhibit multimodal vascular activity beyond their effects on BP, although whether these are important remains to be established. The rest of the article fleshes out these assertions.

Seven randomized controlled trials have assessed whether antihypertensive drugs prevent recurrence in patients with previous stroke or transient ischemic attack (TIA).1 Two trials (2193 patients) used a β-receptor antagonist (β-RA, atenolol), recorded a small fall in BP (5/3 mm Hg), and were neutral, ie, there was no protective vascular effect.2,3 Three trials (6216 patients) studied a diuretic4–6; …