Antihypertensive Therapy for CVA Patients

Primary Recommendation

The American Heart Association recommends the combination of an ACE inhibitor plus a thiazide diuretic as the preferred antihypertensive regimen for patients with a history of cerebrovascular accident, with a target blood pressure of <130/80 mmHg 1, 2
The PROGRESS trial demonstrated that the combination of perindopril (an ACE inhibitor) plus indapamide (a thiazide diuretic) reduced recurrent stroke by 43%, even in patients who were not hypertensive at baseline, which is a Class I, Level A evidence 2
Antihypertensive treatment is Class I, Level A evidence for prevention of recurrent stroke and other vascular events in persons who have had an ischemic stroke beyond the hyperacute period, according to the American College of Cardiology 1
The benefit of antihypertensive treatment extends to all stroke patients regardless of whether they had pre-existing hypertension, as stated by the American Heart Association 1
Target blood pressure should be <130/80 mmHg, though the optimal absolute target requires individualization based on patient factors, such as extracranial cerebrovascular occlusive disease, renal impairment, cardiac disease, and diabetes, as recommended by the American College of Cardiology 1

If the patient cannot tolerate an ACE inhibitor, an angiotensin receptor blocker (ARB) is the preferred alternative, with a favorable safety profile and minimal risk of cough, according to the American College of Cardiology 3

The target blood pressure for stroke prevention is <130/80 mmHg, with gradual reduction to prevent complications from excessive lowering, as recommended by the American Heart Association 1, 3
Blood pressure reduction should be gradual, as large rapid reductions have been associated with ischemic stroke and death, according to the American College of Cardiology 3
Most stroke patients will require two or more antihypertensive agents to achieve target blood pressure, as stated by the American Heart Association 4

All stroke patients should receive statin therapy regardless of baseline cholesterol levels, with a target LDL-C <100 mg/dL (or <70 mg/dL for very high-risk patients), as recommended by the American College of Cardiology 1
Statin administration is reasonable for stroke prevention in patients who have undergone carotid endarterectomy, irrespective of serum lipid levels, according to the American Heart Association 5, 6
Antiplatelet therapy with aspirin (75-325 mg daily), clopidogrel (75 mg daily), or aspirin plus extended-release dipyridamole is recommended for secondary stroke prevention, as stated by the American College of Cardiology 5
Lifestyle modifications including weight reduction, DASH diet, sodium restriction, physical activity, and smoking cessation should accompany pharmacological therapy, as recommended by the American Heart Association 4

The American Heart Association recommends a target blood pressure of <130/80 mmHg for all patients with a history of stroke, as supported by the Hypertension guidelines 7

Dihydropyridine calcium channel blockers, such as amlodipine, can be added as additional therapy if needed, according to the European Heart Journal and Hypertension guidelines 7, 8

The European Heart Journal states that ACE inhibitors, ARBs, thiazide diuretics, and calcium channel blockers have all demonstrated effective reduction of blood pressure and cardiovascular events in randomized controlled trials 8
The European Heart Journal reports that the PATS trial using indapamide and the PROGRESS trial using perindopril (often with indapamide) both showed approximately 30% reduction in recurrent stroke 9

The Hypertension guidelines suggest that beta-blockers are not preferred for stroke prevention unless there is a compelling indication (e.g., post-MI, stable angina) 7
The European Heart Journal recommends that if blood pressure is not controlled with a three-drug combination, spironolactone should be added as the fourth agent 8