From the Guidelines
After a recent stroke, the most effective approach to managing blood pressure and preventing recurrence is to use antihypertensive medications such as ACE inhibitors or ARBs, with a target blood pressure of less than 130/80 mmHg, as recommended by the most recent guidelines 1. The choice of specific agents is less important than achieving the target blood pressure, and medications such as diuretics, ACE inhibitors, and ARBs have been shown to be effective in reducing the risk of recurrent vascular events in patients with stroke or TIA 1. Some key points to consider when managing blood pressure after a stroke include:
- Using a combination of medications, such as ACE inhibitors (like ramipril 2.5-10mg daily or perindopril 4-8mg daily) or ARBs (like candesartan 8-32mg daily), along with a thiazide diuretic (such as indapamide 1.5mg daily or chlorthalidone 12.5-25mg daily) to achieve the target blood pressure 1.
- Gradually achieving the target blood pressure over several weeks to avoid complications from sudden drops 1.
- Beginning treatment within 24-48 hours after the stroke is stable, unless blood pressure is severely elevated 1.
- Monitoring blood pressure regularly at home, with readings taken at the same time daily, and making medication adjustments under medical supervision 1. Additionally, most stroke patients should receive antiplatelet therapy (aspirin 81-325mg daily, clopidogrel 75mg daily, or a combination) and a statin medication regardless of cholesterol levels, as recommended by the latest guidelines 1. It's also important to consider lifestyle modifications, such as weight loss, physical activity, and smoking cessation, as part of a comprehensive approach to managing stroke risk factors 1.
From the Research
Medication Recommendations after Recent Stroke
Blood Pressure Management
- The management of blood pressure is crucial in patients who have experienced a recent stroke, as hypertension is a leading cause of morbidity and mortality, accounting for 25-49% of all strokes 2.
- Randomized placebo-controlled trials have demonstrated a 38% reduction in primary stroke with the use of diuretics and beta-blockers in patients with hypertension 2.
- Angiotensin-converting enzyme (ACE) inhibitors have also been shown to reduce the risk of primary stroke, with benefits that may be related to their effects on the renin-angiotensin-aldosterone system more than on blood pressure reduction 2.
- In patients who have experienced a stroke or transient ischemic attack, therapy with a diuretic or a combination of a diuretic plus an ACE inhibitor could be recommended based on available outcome studies 2.
ACE Inhibitors
- Lisinopril is a synthetic, nonsulfhydryl, angiotensin-converting enzyme inhibitor that has been shown to be effective in lowering blood pressure in all grades of essential and renovascular hypertension 3, 4, 5.
- Lisinopril has a prolonged duration of action, allowing for once daily dosing, and is well tolerated with minimal side effects 3, 4, 5.
- The use of ACE inhibitors, including lisinopril, may be associated with a risk of hyperkalemia, particularly in patients with known history of high normal serum potassium levels 6.
Treatment Considerations
- Antihypertensive therapy should be individualized in patients, taking into account their specific needs and medical history 2.
- The choice of medication should be based on the patient's response to treatment, as well as the presence of any comorbid conditions or potential drug interactions 2, 3, 4, 5.