Best Antihypertensive for Patients with History of CVA
For patients with a history of cerebrovascular accident (CVA/stroke), the preferred antihypertensive regimen is an ACE inhibitor combined with a thiazide diuretic, with a target blood pressure of <130/80 mmHg. 1
Primary Evidence-Based Recommendation
The combination of an ACE inhibitor (specifically perindopril) plus a thiazide diuretic (indapamide) reduced recurrent stroke by 43% in the landmark PROGRESS trial, even in patients who were not hypertensive at baseline. 1
This represents 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 of antihypertensive treatment extends to all stroke patients regardless of whether they had pre-existing hypertension. 1
Blood Pressure Targets
Target blood pressure should be <130/80 mmHg for all patients with history of stroke. 2, 1
Blood pressure reduction must be gradual, as large rapid reductions have been associated with ischemic stroke and death. 3, 1
Most stroke patients will require two or more antihypertensive agents to achieve target blood pressure. 1
Alternative Medication Options
If ACE Inhibitor Not Tolerated:
An angiotensin receptor blocker (ARB) is the preferred alternative, with a favorable safety profile and minimal risk of cough. 3, 1
ARBs have minimal risk of bronchospasm, which is particularly important in patients with pulmonary conditions. 3
The LIFE study demonstrated that losartan reduced stroke risk by 25% relative to atenolol (p=0.001) in hypertensive patients with left ventricular hypertrophy. 4, 5
Calcium Channel Blockers:
Dihydropyridine calcium channel blockers (such as amlodipine) can be added as additional therapy if needed. 2
Amlodipine has been shown to reduce blood pressure without significantly affecting cerebral blood flow in hypertensive patients with history of ischemic stroke. 6
Medication Classes with Proven Stroke Prevention Benefit
ACE inhibitors, ARBs, thiazide diuretics, and calcium channel blockers have all demonstrated effective reduction of blood pressure and cardiovascular events in randomized controlled trials. 2
The PATS trial using indapamide and the PROGRESS trial using perindopril (often with indapamide) both showed approximately 30% reduction in recurrent stroke. 2
Important Clinical Considerations
Avoid Beta-Blockers as First-Line:
While beta-blockers are included in general antihypertensive guidelines, they are not preferred for stroke prevention unless there is a compelling indication (e.g., post-MI, stable angina). 2
Conventional beta-blockers can worsen insulin sensitivity and metabolic parameters. 7
Resistant Hypertension Management:
If blood pressure is not controlled with a three-drug combination, add spironolactone as the fourth agent. 2, 3
If spironolactone is not tolerated, consider eplerenone or a beta-blocker if not already indicated. 2
Comprehensive Cardiovascular Risk Management
All stroke patients should receive statin therapy regardless of baseline cholesterol levels, with target LDL-C <100 mg/dL (or <70 mg/dL for very high-risk patients). 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