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Clinical Summary

Secondary stroke prevention: meta-analysis supports intensive BP control

Takeaway

  • Among patients who have experienced stroke, a target BP of <130/80 mmHg is superior to one of <140/90 mmHg for reducing recurrence risk.

Why this matters

  • Optimal target for secondary stroke prevention is unclear.

Key results

  • Trial stopped early for slow recruitment, funding cessation.
  • During mean 3.9-year follow-up, mean BP:
    • 133.2/77.7 mmHg in standard control group.
    • 126.7/74.4 mmHg in intensive control group.
  • Vs standard control, intensive control yielded nonsignificant reduction in recurrent stroke risk (HR, 0.73; P=.15).
  • Pooled meta-analysis of this trial with 3 previous trials (SPS3, PAST-BP, PODCAST) favored intensive control:
    • Relative risk, 0.78 (P=.02).
    • Absolute risk difference, −1.5% (95% CI, −2.6% to −0.4%).
    • Number needed to treat, 67 (95% CI, 39-250).

Expert comment

  • In an editorial, Craig S. Anderson, MD, PhD, writes, “Globally, just under half of the total BP-attributable disease burden occurs in people with systolic BP less than 140 mmHg, and most CV events occur in individuals who have had a previous event….Therefore, any recommendations for the initiation, intensification, and control of BP-lowering treatment for high-risk patients has substantial clinical and public health importance.”

Study design

  • Japanese randomized controlled trial (RESPECT trial; 1514 patients) and updated meta-analysis (4 randomized controlled trials, 4895 patients) comparing intensive vs standardized BP control among patients with previous stroke.
  • Main outcome: recurrent stroke.
  • Funding: Merck & Co., Inc., Kenilworth, NJ, USA; Bristol-Myers Squibb; Towa Pharmaceutical Co, Ltd; Omron Corporation.

Limitations

  • Trial lacked power for primary endpoint.
  • Treatment assignment not masked.
  • None of the trials individually showed significant difference.

References


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