Stroke: A Journal of Cerebral Circulation: Published on April, 2022

High blood pressure (BP) is common after ischemic stroke and associated with a poor functional outcome and increased mortality.

Reducing blood pressure (BP) is a highly effective strategy for long-term stroke prevention. Despite overwhelmingly clear evidence from randomized trials that antihypertensive therapy substantially reduces the risk of stroke in primary prevention, uncertainty still surrounds the issue of BP lowering after cerebrovascular events, and the risk of recurrent stroke, coronary events, and vascular death remains significant.

Important questions in a secondary prevention setting include should everyone be treated regardless of their post-stroke BP, how soon after a stroke should BP-lowering treatment be commenced, how intensively should BP be lowered, what drugs are best, and how should long-term BP control be optimized and monitored.

Authors  review the evidence on BP control after a transient ischemic attack or stroke to address these unanswered questions and draw attention to some recent developments that hold promise to improve management of BP in current practice.

TAKE-HOME MESSAGE

The management of blood pressure (BP) as a crucial strategy for long-term secondary prevention of transient ischemic attack (TIA) or stroke was systematically explored.

Practical challenges to attaining optimal BP control in this population, including persistent high rates of treatment discontinuation, unreliable BP quantification, and concerns related to over-intensive BP lowering.

As supported by available evidence, it is suggested that the vast majority of patients who suffer TIA or stroke should start combination antihypertensive therapy soon, but not immediately, after a TIA or stroke with a regimen including a thiazide/thiazide-like diuretic to achieve a target BP of at least 130/80 mm Hg.

Out-of-office BP measurement can be helpful to inform dose titration and adequacy of control.

Although further large trials are ongoing, it is increasingly likely that there is no simple answer. Different subgroups of patients may need to have their BP lowered (eg, before or after thrombolysis), left alone, or elevated.