Skip to main content Accessibility help
Hostname: page-component-768ffcd9cc-nzrtw Total loading time: 1.373 Render date: 2022-12-03T07:13:32.191Z Has data issue: true Feature Flags: { "useRatesEcommerce": false } hasContentIssue true

Chapter 15 - Prevention of Stroke by Lowering Blood Pressure

from Part V - Prevention

Published online by Cambridge University Press:  15 December 2020

Jeffrey L. Saver
David Geffen School of Medicine, University of Ca
Graeme J. Hankey
University of Western Australia, Perth
Get access


For hypertensive patients without prior stroke, TIA, or other symptomatic vascular disease, anti-hypertensive therapy reducing SBP by 10 mm Hg, is associated with reductions in recurrent stroke (by about one-quarter) and of combined stroke, MI, and vascular death (by about one-fifth). Benefit extends across all ages, race-ethnicities, and pathological stroke subtypes. Combined pharmacological and non-pharmacological therapy to lower blood pressure is indicated in all individuals with SBP> 140 or DBP> 90, and in individuals with SBP 130–139 or DBP 80–89 who have additional vascular risk factors. Non-pharmacological blood pressure lowering is indicated in individuals with SBP 130–139 or DBP 80–89 without important additional vascular risk factors. After an ischaemic stroke or TIA, treatment may be gradually started as early as 24–72 hours after onset. The absolute benefits of antihypertensive therapy increase with greater reductions in BP, and are higher for preventing recurrent stroke than for preventing MI, in both primary and secondary prevention. The degree of BP reduction more greatly influences vascular event prevention than does pharmacological agent class. Nonetheless, unless otherwise indicated, beta-blockers are not a preferred agent, as they show less efficacy for stroke prevention. Calcium channel antagonists, ACE inhibitors, and thiazide diuretics are particularly well-studied.

Stroke Prevention and Treatment
An Evidence-based Approach
, pp. 289 - 296
Publisher: Cambridge University Press
Print publication year: 2020

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)


ACCORD Study Group et al. (2010). Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med, 362, 1575–85.Google Scholar
Blood Pressure Lowering Treatment Trialists’ Collaboration. (2003). Effects of different blood-pressure-lowering regimens on major cardiovascular events: results of prospectively-designed overviews of randomised trials. Lancet, 362, 1527–35.Google Scholar
Boan, AD, Lackland, DT, Ovbiagele, B. (2014). Lowering of blood pressure for recurrent stroke prevention. Stroke, 45, 2506–13.CrossRefGoogle ScholarPubMed
Brunström, M, Carlberg, B. (2018). Association of blood pressure lowering with mortality and cardiovascular disease across blood pressure levels: a systematic review and meta-analysis. JAMA Intern Med, 178(1), 2836.CrossRefGoogle ScholarPubMed
Collins, R, Peto, R, MacMahon, S, Hebert, P, Fiebach, NH, Eberlein, KA, et al. (1990). Blood pressure, stroke, and coronary heart disease. Part 2, short-term reductions in blood pressure: overview of randomised drug trials in their epidemiological context. Lancet, 335(8693), 827–38.Google ScholarPubMed
Ettehad, D, Emdin, CA, Kiran, A, Anderson, SG, Callender, T, Emberson, J, et al. (2016). Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet, 387(10022), 957–67.CrossRefGoogle ScholarPubMed
Huang, Y, Cai, X, Li, Y, Su, L, Mai, W, Wang, S, et al. (2014). Prehypertension and the risk of stroke: a meta-analysis. Neurology, 82, 1153–61.CrossRefGoogle ScholarPubMed
Kim, S, Shin, DW, Yun, JM, Hwang, Y, Park, SK, Ko, YJ, et al. (2016). Medication adherence and the risk of cardiovascular mortality and hospitalization among patients with newly prescribed antihypertensive medications. Hypertension, 67, 506–12.CrossRefGoogle ScholarPubMed
Law, MR, Morris, JK, Wald, NJ. (2009). Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ, 338, b1665. doi:10.1136/bmj.b1665.CrossRefGoogle ScholarPubMed
Lee, M, Saver, JL, Chang, B, Chang, KH, Hao, Q, Ovbiagele, B, et al. (2011). Presence of baseline prehypertension and risk of incident stroke: a meta-analysis. Neurology, 77, 13301337.CrossRefGoogle ScholarPubMed
Lee, M, Saver, JL, Hong, K-S, Hao, Q, Ovbiagele, B. (2012). Does achieving an intensive versus usual blood pressure level prevent stroke? Ann Neurol, 71, 133140.CrossRefGoogle ScholarPubMed
Liu, L, Wang, Z, Gong, L, Zhang, Y, Thhijs, L, Staessen, JA, et al. (2009). Blood pressure reduction for the secondary prevention of stroke: a Chinese trial and a systematic review of the literature. Hypertens Res, 32, 1032–40.CrossRefGoogle Scholar
MacMahon, S, Peto, R, Cutler, J. (1990). Blood pressure, stroke, and coronary heart disease. Part 1, prolonged differences in blood pressure: prospective observational studies corrected for the regression dilution bias. Lancet, 335, 765–74.CrossRefGoogle ScholarPubMed
Perkovic, V, Rodgers, A. (2015). Redefining blood-pressure targets – SPRINT starts the marathon. N Engl J Med, 373, 2175–8.CrossRefGoogle ScholarPubMed
PROGRESS Collaborative Group. (2001). Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6,105 individuals with previous stroke or transient ischaemic attack. Lancet, 358, 1033–41.Google Scholar
Sardana, M, Syed, AA, Hashmath, Z, Phan, TS, Koppula, MR, Kewan, U, et al. (2017). Beta-blocker use is associated with impaired left atrial function in hypertension. J Am Heart Assoc, 6. doi:10.1161/JAHA.116.005163.CrossRefGoogle ScholarPubMed
Sipahi, I, Swaminathan, A, Natesan, V, Debanne, SM, Simon, DI, Fang, JC. (2012). Effect of antihypertensive therapy on incident stroke in cohorts with prehypertensive blood pressure levels: a meta-analysis of randomized controlled trials. Stroke, 43, 432–40.CrossRefGoogle ScholarPubMed
SPRINT MIND Investigators for the SPRINT Research Group. (2019). Effect of intensive vs standard blood pressure control on probable dementia: a randomized clinical trial. JAMA, 322, 169–70.Google Scholar
SPRINT Research Group et al. (2015). A randomized trial of intensive versus standard blood-pressure control. N Engl J Med, 373, 2103–16.Google Scholar
Sundstrom, J, Arima, H, Jackson, R, Turnbull, F, Rahimi, K, Chalmers, J, et al. (2015). Effects of blood pressure reduction in mild hypertension: a systematic review and meta-analysis. Ann Intern Med, 162, 184–91.CrossRefGoogle ScholarPubMed
Turner, GM, Calvert, M, Feltham, MG, Ryan, R, Fitzmaurice, D, Cheng, KK, et al. (2016). Under-prescribing of prevention drugs and primary prevention of stroke and transient ischaemic attack in UK general practice: a retrospective analysis. PLoS Med, 13, e1002169.CrossRefGoogle ScholarPubMed
Whelton, PK, Carey, RM, Aronow, WS, Casey, DE Jr, Collins, KJ, Dennison Himmelfarb, C, et al. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension, 71(6), e13e115.Google Scholar
Zonneveld, TP, Richard, E, Vergouwen, MD, Nederkoorn, PJ, de Haan, R, Roos, YB, et al. (2018). Blood pressure-lowering treatment for preventing recurrent stroke, major vascular events, and dementia in patients with a history of stroke or transient ischaemic attack. Cochrane Database Syst Rev, 7. CD007858. doi:10.1002/14651858.CD007858.pub2.Google ScholarPubMed

Save book to Kindle

To save this book to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the or variations. ‘’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats