What is the recommended antihypertensive medication for a patient with a history of stroke and impaired renal (kidney) function?

Recommended Blood Pressure Medication for Stroke and Kidney Failure

For a patient with a history of stroke and kidney failure, the recommended first-line antihypertensive regimen is an ACE inhibitor (such as lisinopril) combined with a thiazide diuretic (such as indapamide), with a target blood pressure of <130/80 mmHg. 1, 2, 3

Primary Medication Recommendation

ACE Inhibitor Plus Thiazide Diuretic Combination

• This combination has Class I, Level A evidence for secondary stroke prevention, demonstrating a 43% reduction in recurrent stroke in the PROGRESS trial, even in patients who were not hypertensive at baseline. 1, 3

• The benefit of antihypertensive treatment extends to all stroke patients regardless of pre-existing hypertension status. 1, 3

• This regimen is specifically recommended for patients with both cerebrovascular disease and chronic kidney disease (CKD), provided the estimated glomerular filtration rate (eGFR) is >30 mL/min/1.73 m². 1

Dosing Adjustments for Renal Impairment

For ACE Inhibitors (Lisinopril Example):

• If creatinine clearance is ≥30 mL/min: Start with standard dosing (5-10 mg daily). 4

• If creatinine clearance is 10-30 mL/min: Reduce initial dose to 5 mg daily, titrate as tolerated to maximum 40 mg daily. 4

• If creatinine clearance is <10 mL/min or on hemodialysis: Start with 2.5 mg once daily. 4

• Monitor serum creatinine and potassium levels closely; a 10-25% increase in serum creatinine may occur initially and is acceptable. 1

Alternative if ACE Inhibitor Not Tolerated

Angiotensin Receptor Blocker (ARB) Plus Thiazide Diuretic

• If the patient develops ACE inhibitor-related side effects (particularly cough), substitute an ARB such as losartan or valsartan. 3, 5

• ARBs have a favorable safety profile with minimal risk of cough and were shown to be noninferior to ACE inhibitors in clinical trials. 1

• Important caveat: ARBs carry the same risk of renal dysfunction as ACE inhibitors in susceptible patients, so similar monitoring is required. 6

Blood Pressure Target

• Target systolic BP of 120-129 mmHg is recommended for patients with history of stroke who are receiving BP-lowering drugs, if tolerated. 1, 2

• For patients with CKD and eGFR >30 mL/min/1.73 m², this same target (120-129 mmHg systolic) is recommended. 1

• BP reduction should be gradual, as large rapid reductions have been associated with ischemic stroke and death. 3

Additional Agents if Target Not Achieved

Third-Line Agent:

• Add a dihydropyridine calcium channel blocker (such as amlodipine) if BP remains uncontrolled on ACE inhibitor plus thiazide diuretic. 1, 3

• Calcium channel blockers are effective in reducing stroke risk and are well-tolerated in patients with renal impairment. 1, 7

Fourth-Line Agent:

• Consider spironolactone if BP remains elevated despite three-drug therapy, provided adequate renal function (eGFR >30 mL/min) and close monitoring of potassium levels. 1, 3

Medications to Avoid

• Beta-blockers are not preferred for stroke prevention unless there is a compelling indication such as post-myocardial infarction or stable angina. 3

• Non-dihydropyridine calcium channel blockers (verapamil, diltiazem) should be avoided if the patient has heart failure. 2

• Alpha-blockers should only be used if other medications fail to achieve BP control. 2

Monitoring Requirements

• Check serum creatinine and potassium within 1-2 weeks of initiating ACE inhibitor or ARB therapy and after dose adjustments. 1

• Renal function may fluctuate in stroke patients with AF due to infection or dehydration, requiring careful ongoing monitoring. 8

• Most stroke patients will require two or more antihypertensive agents to achieve target BP. 3

Critical Clinical Considerations

• Avoid ACE inhibitors and ARBs in bilateral renal artery stenosis or unilateral stenosis in a solitary kidney, as these conditions make renal function angiotensin-dependent. 6

• In patients with severe volume depletion or heart failure, start with lower doses to minimize risk of acute kidney injury. 4, 6

• The combination of ACE inhibitor plus ARB is not recommended as it increases risk of hyperkalemia and acute kidney injury without additional cardiovascular benefit. 9