New research presented at the American Heart Association's scientific sessions reveals challenges and new approaches to managing blood pressure in patients who have had a stroke or have diabetes, STAT reported.
Three separate studies, all presented this past weekend, investigated different strategies for blood pressure control in these high-risk populations. The findings highlight a critical need for a more integrated and nuanced approach to care, moving beyond a one-size-fits-all model for managing a condition that remains the most important modifiable risk factor for recurrent stroke.
Spironolactone: A New Role for an Old Drug
A small but diverse trial, known as REDUCE, tested the use of a common diuretic called spironolactone in the immediate aftermath of a stroke. This medication is typically given to people late in treatment, after three other medications haven’t worked.
The study found that when spironolactone was administered to individuals shortly following their stroke, they had a greater probability than those undergoing conventional post-stroke care of experiencing a reduction in their blood pressure three months later to under 130/80 mm Hg.
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“Blood pressure is defined in guidelines as the most important modifiable risk factor for recurrent stroke,” said Jordana Cohen, associate professor of medicine at the Perelman School of Medicine at the University of Pennsylvania. “We know that blood pressure control after stroke is suboptimal.”
Cohen emphasized the clinical importance of even modest reductions. “When blood pressure goes down by as little as 7 mm, that reduction has been associated with a 38% lower risk of recurrent stroke,” she noted. The study, presented as an abstract, has not yet been published in a medical journal. Its focus was on blood pressure reduction, not on cardiovascular outcomes, leaving questions about its long-term clinical impact.
Targeting Lower Pressure: A Tale of Two Populations
The second and third studies, both published in the New England Journal of Medicine, investigated the clinical effects of aiming for a more aggressive systolic blood pressure target of 120 mm Hg or lower, compared to the currently recommended 140 mm Hg.
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The OPTIMAL-STROKE trial, conducted in Brazil, focused on post-stroke patients. It found that individuals who took medications to attain this lower systolic blood pressure objective were considerably less prone to die or experience cardiovascular events—including heart attack, stroke, and hospitalization for chest pain or heart failure—within a four-year span than those who received standard treatment to reduce levels below 140 mm Hg.
However, achieving this lower target will require medical supervision, including monitoring kidney function. The researchers noted changes in electrolyte levels consistent with using a diuretic, though there was no increase in the risk of end-stage renal disease, the need for dialysis, or in deaths.
In stark contrast, the related OPTIMAL-DIABETES trial, which enrolled patients with type 2 diabetes, yielded neutral results. For those with type 2 diabetes, setting a goal of a systolic blood pressure below 120 mm Hg instead of below 140 mm Hg did not diminish the incidence of major cardiovascular events or deaths.
“I think it very strongly suggests that this trial supports rather than rebukes what we already have seen in other trials treating hypertension more aggressively in patients with diabetes,” said Shawna Nesbitt of UT Southwestern Medical Center.
“We might begin to think about blood pressure treatment in a more nuanced way. That is to say, perhaps we’ve been lumping patients together in a way that may not necessarily always be advantageous.”
Spironolactone May Help Stroke Patients Reach Blood Pressure Targets
- For stroke patients, an older, cheap diuretic (spironolactone) given early after an event may help more people reach a blood pressure target of less than 130/80 mm Hg, potentially reducing future stroke risk.
- Lowering blood pressure aggressively to a top number of 120 mm Hg after a stroke may significantly reduce the risk of death or cardiovascular events, but requires medical supervision, including monitoring kidney function.
- For individuals with type 2 diabetes, setting a target of a systolic blood pressure under 120 mm Hg rather than under 140 mm Hg did not lower the frequency of major cardiovascular events or deaths.
The Challenge of Care Coordination
Stroke patients are often managed by neurologists in the hospital and then transition to primary care. “How does a nephrologist and a neurologist and a primary care person manage the utilization of the medications?” Bruce Ovbiagele of the UCSF Weill Institute for Neurosciences asked.
Cheryl Bushnell of Wake Forest University summarized the core issue. “It’s not the what, but it’s the how,” she stated. “Managing blood pressure in stroke patients is incredibly difficult, I say as somebody who has to own that as a clinician. Is it the neurologist? Is it the nephrologist? "Is it the primary care doctor?" This fragmentation prevents consistent, long-term blood pressure control needed to prevent recurrent events.”
Patients Should Monitor Kidney Function and Electrolyte Levels
The use of more intensive blood pressure-lowering regimens, particularly with drugs like spironolactone or when targeting very low systolic pressure, requires careful monitoring.
Patients with kidney disease or a history of high potassium levels should discuss the risks and benefits of these treatments with their healthcare provider. Any new medication regimen for blood pressure must be managed by a qualified medical professional who can monitor for side effects such as electrolyte imbalances or changes in kidney function.
Individuals who have had a stroke or have diabetes should consult their doctor to establish a personalized blood pressure management plan, rather than attempting to adjust their medications based on new research findings.
| Trial Name | Population | Intervention | Key Findings |
|---|---|---|---|
| REDUCE | Post-stroke patients | Early use of spironolactone | More likely to achieve BP < 130/80 mm Hg three months later vs. usual post-stroke care |
| OPTIMAL-STROKE | Post-stroke patients | Intensive BP targeting (< 120 mm Hg) | Significantly less likely to die or have cardiovascular events within four years |
| OPTIMAL-DIABETES | Patients with type 2 diabetes | Intensive BP targeting (< 120 mm Hg) | Did not reduce the occurrence of major cardiovascular events or deaths vs. target below 140 mm Hg |
Blood Pressure Targets Differ for Stroke and Diabetes Populations
The divergent results for stroke and diabetes populations suggest that the ideal blood pressure target is not uniform across all high-risk groups.
References
- Cohen, J., et al. REDUCE Trial Abstract. Presented at the American Heart Association Scientific Sessions.
- Sampaio, G., et al. OPTIMAL-STROKE Trial. New England Journal of Medicine.
- Santo, K., et al. OPTIMAL-DIABETES Trial. New England Journal of Medicine.
- American Heart Association. High Blood Pressure in Stroke and Diabetes: New Research and Challenges.
