What is the management for a 72-year-old African American male with Hypertension (HTN) and Type 2 Diabetes Mellitus (DM2) who had a left Sylvian stroke?

From the Guidelines

For a 72-year-old African American male with hypertension and type 2 diabetes mellitus who had a left Sylvian stroke, management should prioritize blood pressure control, targeting <130/80 mmHg long-term, with initial antihypertensive therapy using thiazide diuretics and calcium-channel blockers as first-line agents, as recommended by the 2017 American College of Cardiology/American Heart Association hypertension guideline 1.

Acute Management

In the acute phase, blood pressure management is crucial, with targets of <185/110 mmHg before thrombolysis and then 140-180/80-105 mmHg, using medications like labetalol or nicardipine. The patient should be admitted to a stroke unit for close monitoring, with urgent brain imaging (CT or MRI) if not already performed. Acute treatment depends on timing and may include thrombolysis with IV alteplase if within 4.5 hours of symptom onset or mechanical thrombectomy if large vessel occlusion is present and within the appropriate time window.

Secondary Prevention

For secondary prevention, antiplatelet therapy should be initiated promptly with aspirin 81-325 mg daily, potentially followed by clopidogrel 75 mg daily or aspirin-dipyridamole combination. Statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily) should be started regardless of baseline cholesterol levels, as recommended by the American Heart Association/American Stroke Association council on stroke 1. The patient's diabetes requires immediate attention with blood glucose monitoring and appropriate therapy, initially aiming for levels between 140-180 mg/dL in the acute phase.

Long-term Management

Long-term management should focus on controlling hypertension, diabetes, and hyperlipidemia to prevent recurrence. Hypertension management should target <130/80 mmHg, preferably using thiazide diuretics and calcium-channel blockers as first-line agents, given the patient's diabetes and African American ethnicity 1. Early rehabilitation assessment and therapy are essential, including physical, occupational, and speech therapy as needed. This comprehensive approach addresses both the acute stroke management and the underlying vascular risk factors to prevent recurrence.

From the FDA Drug Label

Control of high blood pressure should be part of comprehensive cardiovascular risk management, including, as appropriate, lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake Many patients will require more than one drug to achieve blood pressure goals. Relative risk reduction from blood pressure reduction is similar across populations with varying absolute risk, so the absolute benefit is greater in patients who are at higher risk independent of their hypertension (for example, patients with diabetes or hyperlipidemia), and such patients would be expected to benefit from more aggressive treatment to a lower blood pressure goal Some antihypertensive drugs have smaller blood pressure effects (as monotherapy) in black patients, and many antihypertensive drugs have additional approved indications and effects (e.g., on angina, heart failure, or diabetic kidney disease).

The management for a 72-year-old African American male with Hypertension (HTN) and Type 2 Diabetes Mellitus (DM2) who had a left Sylvian stroke should include:

• Comprehensive cardiovascular risk management
• Blood pressure control with possibly more than one drug to achieve blood pressure goals
• Consideration of additional approved indications and effects of antihypertensive drugs, such as effects on diabetic kidney disease
• Aggressive treatment to a lower blood pressure goal due to the patient's higher risk independent of their hypertension, as they have diabetes 2
• Selection of therapy considering the patient's race, as some antihypertensive drugs have smaller blood pressure effects in black patients 2 3

From the Research

Management of Hypertension and Type 2 Diabetes Mellitus in a Patient with a Left Sylvian Stroke

The management of a 72-year-old African American male with hypertension (HTN) and Type 2 Diabetes Mellitus (DM2) who had a left Sylvian stroke involves a comprehensive approach to control blood pressure and reduce the risk of cardiovascular disease.

• The first-line therapy for hypertension is lifestyle modification, including weight loss, a healthy dietary pattern with low sodium and high potassium intake, physical activity, and moderation or elimination of alcohol consumption 4.
• The decision to initiate antihypertensive medication should be based on the level of blood pressure and the presence of high atherosclerotic cardiovascular disease risk 4.
• First-line drug therapy for hypertension consists of a thiazide or thiazide-like diuretic, an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, and a calcium channel blocker, which should be titrated according to office and home blood pressure levels to achieve a target blood pressure of less than 130/80 mm Hg 4, 5.
• In patients with diabetes mellitus, combination therapy should include an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, plus a thiazide diuretic or a calcium channel blocker 5.
• For black patients, at least one agent should be a thiazide diuretic or a calcium channel blocker 5.

Considerations for Patients with High Cardiovascular Risk

• Patients with high cardiovascular risk, such as those with a history of stroke, should be treated with a combination of antihypertensive and antilipemic therapy to reduce the risk of atherosclerotic complications 6.
• The base of the therapeutic strategy should be a poly-pharmacologic treatment with an ACE inhibitor, calcium antagonist, statin, and antiplatelet therapy if necessary 6.
• The prescription of antihypertensive drugs and the achievement of blood pressure targets should be assessed in accordance with current clinical guidelines for the management of arterial hypertension and hypercholesterolemia 7.

Real-World Clinical Practice

• In real clinical practice, there remains significant uncertainty in the effectiveness and rationality of antihypertensive therapy, despite the wide availability of antihypertensive drugs and the presence of recommendations for a stepwise approach to prescribing combinations of specific groups of antihypertensive drugs 7.
• The prescription of combination therapy mainly differed from the recommended combinations by the wider use of drugs from the beta-adrenoblocker group 7.
• The achievement of blood pressure and low-density lipoprotein cholesterol targets was insufficient in all analyzed groups 7.