Can Systolic Pause Cause Stroke?
Yes, systolic pauses can cause stroke, particularly when they occur during daytime hours, as they are associated with increased cardiovascular risk and mortality. 1
Mechanism and Risk
- Intermediate pauses (2-3 seconds) during daytime are associated with a 2.35-fold increased risk of mortality and higher rates of adverse cardiovascular events, including stroke and transient ischemic attack (TIA) 1
- Systolic blood pressure variability serves as a significant predictor of stroke incidence, with higher variability associated with a 21% increased risk of ischemic stroke and a 73% increased risk of hemorrhagic stroke 2
- Patients with greater fluctuations in systolic blood pressure experience significantly earlier stroke events and reduced stroke-free survival 2
Hypertension and Stroke Risk
- Hypertension is a major modifiable risk factor for stroke, with a direct, continuous, and independent relationship between blood pressure and stroke risk 3
- For each 10-mmHg increase in blood pressure, the risk of stroke increases by 30% to 45% 3
- In the Framingham Heart Study, there was a 2-fold greater risk of carotid stenosis for each 20-mmHg increase in systolic blood pressure 3
- Systolic blood pressure is a better predictor of stroke than diastolic blood pressure in middle-aged and elderly individuals 4
Blood Pressure Management for Stroke Prevention
- Antihypertensive therapy reduces the risk of stroke by approximately 33% for each 10-mmHg reduction in systolic blood pressure 3
- Meta-analysis of 17 hypertension treatment trials found a 38% reduction in risk of stroke and 40% reduction in fatal stroke with antihypertensive therapy 3
- Current guidelines recommend maintaining blood pressure below 140/90 mmHg in the general population with hypertension and asymptomatic extracranial carotid or vertebral atherosclerosis 3
- For patients with isolated systolic hypertension, treatment has shown a 42% reduction in stroke risk 3
Special Considerations for Acute Stroke Management
- In acute ischemic stroke, blood pressure management depends on whether the patient is receiving reperfusion therapy 3:
- For patients eligible for intravenous thrombolysis or mechanical thrombectomy, blood pressure should be lowered and maintained at <180/105 mmHg for at least 24 hours after treatment 3
- For patients not receiving reperfusion therapy, there is no evidence for actively lowering BP unless it is extremely high (>220/120 mmHg) 3
- In acute intracerebral hemorrhage, immediate BP lowering (within <6 hours) to a systolic target of <140 mmHg may reduce the risk of hematoma expansion 3
Left Ventricular Dysfunction and Stroke
- Left ventricular systolic dysfunction may be associated with increased risk of recurrent stroke 5
- In patients with left ventricular systolic dysfunction and cryptogenic stroke with atrial cardiopathy, apixaban was associated with a significantly lower risk of recurrent ischemic stroke compared to aspirin 5
Prevention Strategies
- Regular blood pressure monitoring to identify and manage both hypertension and blood pressure variability 2
- Antihypertensive treatment should be initiated for patients with hypertension to reduce stroke risk 3
- Lifestyle modifications including weight reduction, limitation of alcohol intake, increased physical activity, reduced sodium intake, smoking cessation, and DASH diet are recommended 3
- For patients with a history of stroke or TIA and an indication for BP lowering, it is recommended that BP-lowering therapy be commenced before hospital discharge 3
Clinical Implications
- Monitoring for systolic pauses, particularly during daytime hours, may help identify patients at higher risk for stroke 1
- Blood pressure variability should be considered an important risk factor for stroke, independent of mean blood pressure levels 2
- Patients who experience a stroke have significantly higher long-term mortality (65.6% vs 40.6% at 14.3 years follow-up) compared to those without stroke 6
- Chlorthalidone-based antihypertensive treatment has been shown to reduce the risk of cardiovascular death in long-term follow-up 6