What is a good antihypertensive for a patient with Cerebrovascular Accident (CVA)?

Antihypertensive Selection for CVA Patients

For patients with a history of cerebrovascular accident (CVA/stroke), the combination of an ACE inhibitor plus a thiazide diuretic is the preferred antihypertensive regimen, with a target blood pressure of <130/80 mmHg. 1

Primary Recommendation: ACE Inhibitor + Thiazide Diuretic

The PROGRESS trial demonstrated that the combination of perindopril (an ACE inhibitor) plus indapamide (a thiazide diuretic) reduced recurrent stroke by 43%, even in patients who were not hypertensive at baseline. 1 This benefit was directly related to blood pressure reduction achieved by combination therapy, whereas perindopril monotherapy (which only lowered BP by 5/3 mmHg) showed no significant stroke reduction. 1

• Antihypertensive treatment is Class I, Level A evidence for prevention of recurrent stroke and other vascular events in persons who have had an ischemic stroke beyond the hyperacute period. 1
• The benefit extends to all stroke patients regardless of whether they had pre-existing hypertension. 1
• Target blood pressure should be <130/80 mmHg, though the optimal absolute target requires individualization based on patient factors such as extracranial cerebrovascular occlusive disease, renal impairment, cardiac disease, and diabetes. 1

Alternative Options When ACE Inhibitors Are Not Tolerated

If the patient cannot tolerate an ACE inhibitor (e.g., due to cough), an angiotensin receptor blocker (ARB) is the preferred alternative. 2

• ARBs have a favorable safety profile with minimal risk of cough and do not increase risk of bronchospasm. 2
• The LIFE study showed that losartan (an ARB) reduced stroke risk by 25% compared to atenolol in hypertensive patients with left ventricular hypertrophy. 3
• Losartan is FDA-approved specifically to reduce the risk of stroke in patients with hypertension and left ventricular hypertrophy. 3

Calcium Channel Blockers as Additional Therapy

Calcium channel blockers, particularly dihydropyridines like amlodipine, can be added as second-line agents or used when other classes are contraindicated. 1, 4

• The Syst-EUR trial demonstrated significant reductions in stroke and all cardiovascular disease with the dihydropyridine CCB nitrendipine compared with placebo. 1
• Amlodipine effectively lowers blood pressure without adversely affecting cerebral blood flow in stroke patients, making it particularly suitable for this population. 4
• Calcium channel blockers do not adversely affect pulmonary circulation, which is relevant for patients with concurrent pulmonary conditions. 2

Blood Pressure Management Targets

The target blood pressure for stroke prevention is <130/80 mmHg, with gradual reduction to prevent complications from excessive lowering. 1, 2

• Blood pressure reduction should be gradual, as large rapid reductions have been associated with ischemic stroke and death. 2
• Most stroke patients will require two or more antihypertensive agents to achieve target blood pressure. 1
• Starting or restarting antihypertensive therapy during hospitalization is reasonable for neurologically stable patients with BP >140/90 mmHg. 1

Agents to Avoid or Use with Caution

Beta-blockers show less consistent benefits for stroke prevention compared to diuretics and should not be first-line therapy for stroke patients. 1

• Several randomized controlled trials demonstrated reduction in cardiovascular disease with beta-blockers, but benefits are less consistent than with diuretics. 1
• In the LIFE study, the beta-blocker atenolol was inferior to losartan for stroke prevention, with 25% more strokes in the atenolol group. 1, 3
• Conventional beta-blockers may worsen insulin sensitivity and metabolic parameters, which are important cardiovascular risk factors. 5

Additional Cardiovascular Risk Management

All stroke patients should receive statin therapy regardless of baseline cholesterol levels, with a target LDL-C <100 mg/dL (or <70 mg/dL for very high-risk patients). 1

• Statin administration is reasonable for stroke prevention in patients who have undergone carotid endarterectomy, irrespective of serum lipid levels. 1
• Antiplatelet therapy with aspirin (75-325 mg daily), clopidogrel (75 mg daily), or aspirin plus extended-release dipyridamole is recommended for secondary stroke prevention. 1
• Lifestyle modifications including weight reduction, DASH diet, sodium restriction, physical activity, and smoking cessation should accompany pharmacological therapy. 1

Common Pitfalls to Avoid

• Do not delay antihypertensive therapy in neurologically stable stroke patients with BP >140/90 mmHg, as early treatment (within 2 weeks) is reasonable when there are no contraindications. 1
• Do not use monotherapy when combination therapy is needed; most patients require 2-3 agents to achieve target BP. 1
• Do not select beta-blockers as first-line therapy for stroke prevention given their inferior efficacy compared to diuretics and ACE inhibitors. 1
• Do not neglect blood pressure control in the acute setting (>24 hours post-stroke), where cautious reduction is appropriate for severely elevated pressures. 1