Target Blood Pressure Goals in Cerebrovascular Disease

Abstract

The second most attributed cause of mortality and morbidity globally is stroke and it accounts for the third most common cause of disability.[1] Elevated blood pressure is a common modifiable risk factor as confirmed in several studies. Hypertension is observed in an estimated 64% of stroke patients with approximately 51% of stroke mortality being attributed to hypertension worldwide.[2,3] Screening and early optimal treatment of hypertension at community level presents many missed opportunities to reduce the burden of stroke. Hypertension contributes as a major risk factor for both ischemic and hemorrhagic stroke.[3] The relationship between hypertension and cerebrovascular disease risk is well established and the causal association has been confirmed with a progressively graded association with increasing BP values.[2] The relationship between BP and cerebrovascular events is continuous, making the distinction between normal BP and hypertension, based on cutoff BP values, somewhat ambiguous. Progressively higher BP value entails greater risk of stroke in both non-hypertensive and hypertensive range of BP values. The definition of hypertension is the level of raised BP above normal values at which the benefits of treatment (either with lifestyle interventions or drugs) unequivocally outweigh the risks of treatment, as documented by clinical trials. More than two-third of individuals above age of 65 years are diagnosed to have hypertension. Although awareness and treatment of hypertension has improved over the past two decades, control rates are around 50%. The European Guidelines for the Management of Hypertension recommend aiming to achieve a target systolic BP to <140 mmHg for all patient categories, including independent elderly patients, with an ideal target of 130 mmHg for all patients if tolerated [Table 1].[4] Isolated systolic hypertension in the elderly also contributes to the risk of stroke. The deleterious contribution of hypertension as a risk factor in stroke is based on a continuum rather than a threshold effect. Epidemiological studies have concluded that optimal BP control reduces the risk of stroke and for every 10 mmHg control of systolic blood pressure by onethird in patients aged 60–79 years. This benefit is sustained up to BP level of 115/75 mmHg and is observed in all stroke subtypes, both genders, and all age groups. SBP ≥ 140 mmHg contributes to about 70% of the mortality and disability burden. Both office BP and home or ambulatory BP have an independent and Abstract