(Stroke. 2000;31:415.)
© 2000 American Heart Association, Inc.
Original Contributions |
Blood Pressure Exceeding National Guidelines Among Women After Stroke
From the Departments of Internal Medicine (W.N.K., C.M.V., R.I.H.), Epidemiology and Public Health (L.M.B., R.W.M., R.I.H.), Neurology (L.M.B.), Psychiatry (P.M.S.), and Obstetrics and Gynecology (P.M.S.), Yale University School of Medicine, New Haven, Conn; and the Veterans Administration Connecticut Healthcare System (L.M.B.).
Correspondence and reprint requests to Walter N. Kernan, MD, Primary Care Center, Yale-New Haven Hospital, 20 York St, New Haven, CT 06504. E-mail walter.kernan{at}yale.edu
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Abstract |
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Background and Purpose—After a transient ischemic attack or stroke, the risk for recurrence may be reduced by treatment of hypertension. The purpose of this study was to determine how commonly blood pressure exceeds national guidelines among patients who have had one of these events.
Methods—Subjects were 644 women participating in a randomized trial of estrogen for secondary stroke prevention. We measured blood pressure 1 month after the stroke or TIA while patients were under the care of their personal physicians. Among 536 patients, a second measure was made at an average of 2.9 years after the first.
Results—The mean age of participants was 71 years, and 73% reported a history of hypertension. At baseline, only 44% (280/644) of the women had blood pressure values within national guidelines (<140/90 mm Hg). With separate guidelines used for diabetics (<130/85 mm Hg) and nondiabetics (<140/90 mm Hg), the proportions of women within the guidelines were 27% and 44%, respectively. Overall, 39% of patients were within the diabetes-adjusted guidelines. Among patients whose blood pressure exceeded 140/90 mm Hg at first examination, 55% were still in excess at follow-up. Features associated with severe hypertension at first examination (>160/100 mm Hg) were history of hypertension, education less than college, and higher cognitive functioning.
Conclusions—Blood pressure values in excess of national guidelines are common after stroke and TIA, especially among diabetic patients. Efforts to lower blood pressure control may enhance secondary prevention.
Key Words: cerebrovascular disorders • hypertension • adherence • prognosis • randomized clinical trials • health services research
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Introduction |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Hypertension is the most important remediable risk factor for stroke.1 2 Lowering diastolic blood pressure (DBP) by 5 to 6 mm Hg reduces the odds of any (fatal or nonfatal) stroke by 42% after only 2 to 3 years.3 A similar magnitude of stroke reduction has been observed for isolated systolic hypertension for men and women >60 years old.4 On the basis of these cumulative data, The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) recommends that all persons have their blood pressure measured regularly to achieve and maintain a systolic blood pressure (SBP) <140 mm Hg and a DBP <90 mm Hg and lower if tolerated.5
Research has demonstrated that many hypertensive patients do not
achieve the goals advocated by the JNC. In a cohort of 800 hypertensive
veterans attending an outpatient clinic,6 for example,
only 60% achieved a blood pressure 
160/90 mm Hg. In the 1988
to 1991 National Health and Nutrition Examination Survey, only 24% of
patients with a diagnosis of hypertension achieved a value of
<140/90 mm Hg.7 Research on the reasons for
nonachievement of treatment goals has called attention to patient
factors (eg, medication adherence),8 9 physician factors
(eg, failure to make timely medication changes),6 and
system factors (eg, lack of health insurance).10
Because stroke patients are at high risk for vascular morbidity and mortality, achievement of treatment goals may be particularly important. The research on achievement of hypertension treatment goals, however, has included primarily patients who are free of manifest vascular disease. The few studies among patients with cerebrovascular disease involve small cohorts11 or preliminary communications.12 To closely examine hypertension treatment after stroke among a large population, we examined the achievement of hypertension treatment goals among 644 postmenopausal women who had had a recent TIA or nondisabling ischemic stroke.
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Subjects and Methods |
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Subjects and Data Collection
Eligible subjects included all women participating in the Women’s Estrogen for Stroke Trial (WEST), including those assigned to either active or placebo treatment, for whom a baseline right arm blood pressure was available. The design of the WEST has been published in detail.13 The WEST is an ongoing trial with the primary aim of determining whether 1 mg of 17ß-estradiol, compared with placebo, can reduce the risk of recurrent stroke or death among postmenopausal women who have experienced a recent TIA or nondisabling ischemic stroke. Eligible women were recruited from hospitals and medical practices in Connecticut and Massachusetts. Subjects were required to be >44 years of age, postmenopausal, not on estrogen at the time of their stroke, and free of breast or uterine cancer. In addition, they must have had an expected survival of at least 3 years. Before randomization, blood pressure was measured by registered nurses using aneroid manometers. Measurements were always made with patients sitting after 5 minutes of quiet rest. Two readings were recorded from each arm, but no specific protocol dictated the order in which readings were made or the interval between readings. Systole was defined by the appearance of the first Korotkoff sound and diastole by the disappearance of the fifth.
WEST participants received all medical care from their personal
physicians, including treatment for hypertension. In early
communications, WEST investigators informed personal physicians of the
baseline, prerandomization blood pressure readings for their patients,
encouraged treatment to the JNC guidelines, and provided reference to
those guidelines. By the WEST protocol, follow-up blood pressure
measures were made only when patients were discharged from the study
because of scheduled termination or the occurrence of a nonfatal
stroke. In the event of a stroke, measurements were made 
30 days
later. Beginning in 1998, blood pressures were also obtained during any
home visits by a study nurse. As of July 1999, all patients had been
discharged.
Data Analysis
For the primary analysis in this report, our purpose was
to describe the distribution of SBP and DBP values among WEST
participants 1 month after their stroke. For
DBP, the described categories are 79, 80 to 84, 85 to 89, 90
to 99, and 
100 mm Hg. For SBP, the described categories are
129, 130 to 139, 140 to 159, 160 to 180, and 180 mm Hg. WEST
patients were classified into blood pressure categories on the basis of
the mean of paired readings from the right arm.14 Because
some guidelines suggest the use of readings from the arm with the
highest mean systolic value,5 we conducted a
separate analysis with this criterion.
To provide a summary estimate of blood pressure control that accounts
for both DBP and SBP, in a separate analysis we grouped
patients according to JNC categories.5 Although these
categories were developed to classify blood pressure for adults who are
not on antihypertensive treatment, we believe they provide a familiar
and convenient means to describe severity among treated patients. In
the JNC schema, normal is defined as SBP <130 mm Hg and DBP
<85 mm Hg. High-normal is defined as SBP 130 to 139 mm Hg
or DBP 85 to 89 mm Hg. Stage 1 hypertension is SBP 140 to 159 or
DBP 90 to 99, stage 2 is SBP 160 to 179 or DBP 100 to 109, and stage 3
is SBP 180 or DBP 110. When SBP and DBP fall into different
categories, the higher category is selected.
The basic recommendation of JNC-VI is for all patients to achieve a DBP <90 mm Hg and an SBP <140 mm Hg. We calculated the proportion of our patients who were within this guideline. Because guidelines5 15 commonly recommend different blood pressure treatment goals for diabetics (<130/85) than for nondiabetics (<140/90), we also calculated the proportion of patients within these guidelines.
To identify clinical features of patients at risk for moderately or
severely elevated blood pressure after TIA or ischemic stroke
(ie, SBP 160 or DBP 100), we calculated odds ratios for 12
candidate features. Impaired mental status was defined as a score of
<24 on the Folstein Mini-Mental State Examination.16
Impaired physical functioning was defined as a score <23 points on the
Physical Performance Test.17 Obesity was defined
as a body mass index [weight in kg/(height in meters squared)] >27.
Depression was defined by a score of >16 on the 20-item Center for
Epidemiologic Studies Depression Scale (CES-D).18 Other
features (renal disease, education, race, alcohol use, history of
hypertension, current cigarette use, marital status) were defined by
self-report. Features that were closely associated with severely
elevated blood pressure (odds ratio >1.4 or <0.7) were entered into a
Cox proportional hazards model to calculate adjusted estimates of
effect.
To determine whether participants with a blood pressure >140/90 at baseline are above this criterion at follow-up, we calculated mean blood pressure values at baseline and at follow-up for all WEST patients for whom follow-up blood pressure was available. When multiple follow-up blood pressures were available, we chose the earliest one.
All analyses were performed with the SAS system (SAS Institute Inc). The institutional review committees at all participating hospitals approved this research, and all subjects gave informed consent for participation.
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Results |
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Baseline Characteristics
Among 652 women in the WEST, 644 with a baseline right arm blood pressure composed the cohort for this study. Baseline characteristics of participants are shown in Table 1
. The average age was 71 years.
Among all participants, 84% were white and 16% were minorities. The
qualifying event was a stroke for 74% and TIA for 26%. Comorbid
conditions were common, including diabetes for 32%, prior stroke for
19%, and prior myocardial infarction for 27%. A history of
hypertension was reported by 74% of patients, among whom 84% were on
treatment. In the entire cohort, 71% of patients were on hypertension
medication.
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Blood Pressure in Excess of National Guidelines
As shown the Figure, DBP was
79 mm Hg for 398 patients (62%), 80 to 84 mm Hg for 116
(18%), 85 to 89 mm Hg for 49 (7%), 90 to 99 mm Hg for 62
(10%), and 100 mm Hg for 19 (3%). SBP was 129 mm Hg
for 179 patients (28%), 130 to 139 mm Hg for 109 (17%), 140 to
159 mm Hg for 232 (36%), 160 to 179 mm Hg for 90 (14%),
and 180 mm Hg for 34 (5%). The mean time from entry TIA or
stroke to blood pressure assessment was 37 days.
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As a summary measure of blood pressure status taking account of both SBP and DBP, we calculated the proportion of patients for whom the DBP and SBP were within specific boundaries recommended by the JNC-VI (ie, DBP <90 mm Hg and SBP <140 mm Hg). Only 44% (280/644) of the patients were within this boundary. Using blood pressure readings from the arm with the highest pressure, 38% (246/644) were within the boundary.
The proportion of patients within JNC-VI guidelines (<140/90) differed among patients with and without a history of hypertension. For patients who gave a self-report of hypertension on admission to the WEST, the proportion within the guidelines was 36% (171/472). For patients without a history of hypertension, the proportion was 63% (107/170).
Because JNC5 and American Diabetes
Association15 guidelines recommend lower blood pressure
target values for diabetic patients than for nondiabetic patients, we
calculated the proportion of patients at these separate targets. Among
208 diabetic patients, we defined the target blood pressure according
to American Diabetic Association Guidelines of SBP 130 mm Hg
and DBP 85 mHg. Among 436 nondiabetic patients, we defined the target
blood pressure according to the JNC-VI guidelines of SBP <140
mm Hg and a DBP <90 mm Hg. The proportion of diabetic patients
with blood pressure <130/85 was 27% (57/208), and the proportion of
nondiabetics with blood pressure <140/90 was 44% (192/436). Among
both diabetics and nondiabetics, only 39% (249/644) were within
treatment targets according to the separate criteria. When patients
with and without a history of hypertension were compared by the
diabetes-adjusted analysis, the proportions of patients at
target blood pressure were 32% (149/472) and 58% (98/170),
respectively.
Predictors of Markedly Elevated Blood Pressure
In univariate analysis, 4 clinical
features were associated (RR >1.4 or <0.7) with SBP 160 mm Hg
or DBP 100 mm Hg: history of hypertension, education less than
college, renal disease, or impaired cognition. In a logistic regression
model including these 4 features, only history of hypertension,
education less than college, and impaired mental status remained
important (95% CIs exclude 1). Hypertension and low education
increased risk for uncontrolled blood pressure, but impaired mental
status protected against it.
Temporal Stability of Blood Pressure
Follow-up blood pressure measurements were available for 536 WEST
patients at a mean of 2.9 years from study entry (range, 11 to 2015
days). Measurements were not available for 108 because of death (n=85),
refusal (n=2), or technical reasons (n=21). Mean DBP did not change for
the group defined by baseline DBP 79 mm Hg (n=318) but fell by
9, 12, 12, and 21 mm Hg in groups defined by baseline DBPs of 80
to 84 (n=104), 85 to 89 (n=38), 90 to 99 (n=52), and 100 mm Hg
(n=16), respectively. Compared with the baseline mean SBP, the
follow-up mean pressure rose by 10 mm Hg for the 129 group
(n=150) but fell by 4, 8, 22, and 47 in all other groups defined by
baseline SBPs of 130 to 139 (n=93), 140 to 159 (n=190), 160 to 179
(n=78), and 180 mm Hg (n=25). Mean DBP for the entire group of
536 patients fell from 75 to 70 mm Hg. Mean SBP fell from 142 to
135 mm Hg.
Among the 536 patients for whom follow-up pressure values were
available, 44% (235/536) had a baseline blood pressure value 140/90
compared with 55% (297/536) at follow-up. Among those with a blood
pressure value <140/90 at baseline, 69% (165/235) were still within
this limit at follow-up. Among those who were 140/90 at baseline,
55% (166/301) were still 140/90 at follow-up.
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Discussion |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Our findings indicate that blood pressure in excess of customary guidelines (<140/90) is common 1 month after stroke or TIA. Patients with an elevated pressure at 1 month, furthermore, commonly continue to have an elevation at 3 years.
To identify clinical characteristics of patients with moderately or
severely elevated blood pressure (SBP 160 mm Hg or DBP
100 mm Hg), we performed an analysis that revealed
associations with a history of hypertension, lower educational
attainment, and higher Mini-Mental Status Score. The association of
elevated pressure with hypertension history makes obvious sense. The
association of elevated pressure with lower educational attainment may
plausibly be related to access to care or health awareness. The
association of elevated pressure with higher cognitive functioning is
harder to explain and requires validation in another cohort.
A surprising finding was that among patients with no history of hypertension at baseline, only 64% had a blood pressure <140/90. Although it is plausible that our baseline measurement overestimated patients’ true blood pressure, this seems unlikely, because measurement error in sphygmomanometry usually leads to underestimation. It is also unlikely that our baseline measurements were elevated because of recent stroke. Although blood pressure is increased in the setting of acute stroke, the effect is transitory and resolves within a few days. We believe it is more likely that many of these patients had undiagnosed hypertension. This interpretation is consistent with findings from NHANES III that 31% of patients with hypertension are unaware of their diagnosis.7 In all cases, we notified personal physicians of our findings.
The problem of blood pressure in excess of conventional treatment goals after stroke has received little attention in the medical literature. In fact, we are aware of only 2 reports involving a US cohort.11 12 Schneck and colleagues12 reported that 27% of treated hypertensive patients in the African-American Anti-Platelet Stroke Study have SBP >160 mm Hg or DBP >100 mm Hg. Joseph and colleagues11 reported that >50% of stroke patients attending a stroke clinic had blood pressures exceeding JNC guidelines of 140/90 mm Hg. In each of these reports, hypertension was only 1 of several risk factors examined. To the best of our knowledge, ours is the first original report to focus exclusively on blood pressure in a US cohort.
The paucity of literature on hypertension control after stroke is
surprising, because clues to the magnitude of the problem have existed
in incidental data from clinical trials19 20 and
observational studies.21 22 23 24 25 In the European Atrial
Fibrillation Trial, for example, 76 of 375 patients (20%) in the
placebo group had an SBP at enrollment >160 mm Hg. In the UK TIA
Aspirin Trial,20 1327 of 2435 patients (54%) had a
sustained SBP 150 mm Hg during follow-up over several years (A.
Rodgers, MD, personal communication, May 26, 1998).
The lack of attention to hypertension control after stroke may reflect skepticism on the part of physicians and policy makers that improved blood pressure control is feasible or effective for secondary prevention of stroke. One reason for this skepticism may be the paucity of evidence that hypertension adversely affects prognosis after stroke or that treatment among stroke patients is beneficial.22 26 27 28 Observational studies relating a single blood pressure measurement22 23 24 25 29 30 31 32 33 or serial measures20 22 34 35 to risk of recurrence have produced inconsistent findings. Clinical trials have predominantly supported the hypothesis of a treatment effect, but only 3 exist. Two detected a treatment benefit,36 37 and 1 did not.38 A recent meta-analysis of 6752 stroke patients in 9 trials (including the 3 dedicated randomized clinical trials described above) found that active treatment reduced the incidence of recurrent stroke by 28%.39
Despite the absence of complete and consistent data that hypertension therapy after stroke reduces recurrence or mortality, experts commonly recommend treatment.40 Our findings demonstrate that patients are not achieving these stroke-specific recommendations or the more generally applied recommendation of the JNC. We are particularly concerned about the rate of blood pressure in excess of guidelines among diabetic patients, whose risk for recurrent stroke, cardiac events, and death is twice that of nondiabetic patients.24 33 41 42 Improved hypertension control for diabetics may substantially reduce morbidity and mortality.
Our findings add to the growing literature showing undertreatment of vascular risk factors among patients with symptomatic vascular disease. For patients with heart disease, for example, researchers have detected underuse of ß-blockers,43 aspirin,44 anticoagulation,45 and cholesterol-reducing medications.46 Our detection of a high rate of blood pressure in excess of national guidelines among stroke patients raises the possibility that efforts to reduce blood pressure10 may lower rates of recurrent stroke and other vascular events.
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Acknowledgments |
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This study was funded by grant 1-RO1-N531251-03 from the National Institute of Neurological Diseases and Stroke.
Received August 13, 1999; revision received November 23, 1999; accepted November 23, 1999.
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