Abstract
IntroductionThere is limited knowledge of the effects of blood pressure (BP) lowering on cerebral haemodynamics after transient ischaemic attack (TIA) and non-disabling stroke, particularly at older ages. We aimed to evaluate changes in transcranial Doppler (TCD) haemodynamic indices in patients undergoing early blood pressure lowering after TIA/non-disabling stroke, irrespective of age.Patients and methodsAmong consecutive eligible patients attending a rapid-access clinic with suspected TIA/non-disabling stroke and no evidence of extra/intracranial stenosis, hypertensive ones underwent intensive BP-lowering guided by daily home telemetric blood pressure monitoring (HBPM). Clinic-based BP, HBPM, End-tidal CO2 and bilateral middle cerebral artery (MCA) velocity on TCD were compared in the acute setting versus one-month follow-up; changes were stratified by baseline hypertension (clinic-BP≥140/90) and by age (<65, 65–79 and ≥80).ResultsIn 697 patients with repeated TCD measures, mean/SD baseline systolic-BP (145.0/21.3 mmHg) was reduced by an average of 11.3/19.9 mmHg (p < 0.0001) at one-month (133.7/17.4 mmHg), driven by patients hypertensive at baseline (systolic-BP change = −19.0/19.2 mmHg, p < 0.001; vs −0.5/15.4, p = 0.62 in normotensives). Compared with baseline, a significant change was observed at one-month only in mean/SD MCA end diastolic velocity (EDV) (0.77/7.26 cm/s, p = 0.005) and in resistance index (RI) (−0.005/0.051, p = 0.016), driven by hypertensive patients (mean/SD EDV change: 1.145/6.96 cm/s p = 0.001, RI change −0.007/0.06, p = 0.014). Findings were similar at all ages (EDV change – ptrend=0.357; RI change – ptrend=0.225), including 117 patients aged ≥80. EDV and RI changes were largest in 100 patients with clinic systolic-BP decrease ≥30 mmHg (mean/SD EDV change = 2.49/7.47 cm/s, p = 0.001; RI change −0.024/0.063, p < 0.0001).ConclusionThere was no evidence of worsening of TCD haemodynamic indices associated with BP-lowering soon after TIA/non-disabling stroke, irrespective of age and degree of BP reduction. In fact, EDV increase and RI decrease observed after treatment of hypertensive patients suggest a decrease in distal vascular resistance.
Highlights
There is limited knowledge of the effects of blood pressure (BP) lowering on cerebral haemodynamics after transient ischaemic attack (TIA) and non-disabling stroke, at older ages
Patients with TIA/non-disabling stroke are often started on antihypertensive treatment in the acute setting,[8] the effects of intensive blood pressure lowering on cerebral perfusion in these patients are uncertain, at older ages
A significant increase in transcranial Doppler (TCD) end diastolic velocity (EDV) was consistent across all age groups, with no evidence that older ages are at disproportionately higher risk of reduced velocities with intensive blood pressure reduction early after TIA/non-disabling stroke
Summary
There is limited knowledge of the effects of blood pressure (BP) lowering on cerebral haemodynamics after transient ischaemic attack (TIA) and non-disabling stroke, at older ages. Treatment of hypertension is safe and effective in elderly patients in primary prevention,[1,2,3] with no evidence of cerebral hypoperfusion.[4] Blood pressure (BP) lowering after stroke or transient ischaemic attack (TIA) reduces the risk of recurrent stroke,[5,6] but some uncertainties remain. There is no evidence of benefit, and even possible harm, from acute initiation of treatment in major acute stroke.[7] patients with TIA/non-disabling stroke are often started on antihypertensive treatment in the acute setting,[8] the effects of intensive blood pressure lowering on cerebral perfusion in these patients are uncertain, at older ages. Reduced cerebral blood flow at older ages could place elderly patients at higher risk of cerebral hypoperfusion,[11] those with decreased diastolic flow and increased cerebrovascular resistances, which is associated with cognitive decline.[11,12]
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