Blood Pressure Lowering for Primary and Secondary Prevention of Stroke

Abstract

Hypertension affects from 20% to 30% of the world population.1,2 Blood pressure is the most consistent and powerful predictor of stroke. Population mortality trends for stroke parallel those in hypertension.3,4 A systolic blood pressure >115 mm Hg explains 60% of the population-attributable risk of stroke.5 In the Framingham cohort,6 the lifetime risk of stroke at ages 55, 65, and 75 years was similar, approximating 1 in 5 for women and 1 in 6 for men. In many countries, such as China,7 stroke is the third cause of death only preceded by heart disease and total cancer. Two thirds of stroke deaths occur in developing nations.8 According to recent estimates published by the World Health Organization, worldwide, &15 million people per year fall victim to a stroke, of whom &5 million die and another &5 million are left permanently disabled.1 From this vantage point, we reviewed the recent literature to underscore the deadly but reversible link between stroke and blood pressure. ### Nonmodifiable Risk Factors Nonwhite ethnicity, male sex, older age, and a positive family history are among the nonmodifiable risk factors of stroke.9,10 Monogenic stroke disorders,11 such as, for instance, cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy,12 are extremely rare. In the vast majority of cases, stroke has a polygenic background associated with proven or suspected variation in the genes contributing to hypertension, carotid intima-media thickness, vascular remodeling, small vessel disease,13 inflammation, oxidative stress, dyslipidemia, or the generation of angiotensin II.14,15 Small vessel disease of the brain underlies 20% to 30% of ischemic strokes and a larger proportion of intracerebral hemorrhages.13 ### Modifiable Risk Factors Smoking,1,9,10 excessive alcohol intake (>60 g per day),9,10,16 obesity,9,10 dyslipidemia,9,10 diabetes mellitus,9,17 carotid artery disease,9,10 atrial fibrillation, heart failure, and other forms …