ABSTRACT

Blood pressure lowering has been recognized, even in the popular press, as a very important and effective strategy for both primary and secondary prevention of stroke. According to the July 1999 Consumer Reports, ‘Controlling hypertension is the single most important step most people can take to prevent stroke’. Data from many epidemiologic surveys and cohort studies (for example, The Framingham Heart Study) indicate that stroke is about 2-4 times more common among hypertensive than normotensive people; the higher the blood pressure, the greater the risk. Many randomized clinical trials have shown a substantial reduction in the risk of stroke when antihypertensive medications are provided. A 1990 meta-analysis of such studies estimated that stroke rates were reduced by 42 ± 6% (mean ± standard deviation) when active antihypertensive drugs were used, as compared to placebo. Although lifestyle modifications have a place in hypertension treatment, they are less effective than antihypertensive pills in both lowering blood pressure and preventing stroke. As a result, people at high risk for stroke and other cardiovascular disease should seldom be treated without pills for more than a year. Diuretics, beta-blockers, calcium antagonists and angiotensin-converting enzyme (ACE)-inhibitors have been used as initial antihypertensive drug therapy in clinical trials in

which stroke has been significantly reduced (compared to placebo). Which of these agents is the best initial antihypertensive drug is a controversy that may be resolved when Antihypertensive and Lipid Lowering Heart Attack Trial (ALLHAT) and other large clinical trials are completed. The role of angiotensin II receptor blockers as initial therapy is also being studied; they can be recommended when an angiotensinconverting enzyme ACE-inhibitor causes cough.