Stroke. 2004;35:1579-1583
Published online before print May 20, 2004,
doi: 10.1161/01.STR.0000131547.71502.81
(Stroke. 2004;35:1579.)
© 2004 American Heart Association, Inc.
Comparison of Hypertension Management After Stroke and Myocardial Infarction
Results From ECLAT1A French Nationwide Study
Jacques Amar, MD;
Jean Pierre Cambou, MD;
Emmanuel Touzé, MD;
Vanina Bongard, MD;
Gérard Jullien, MD;
Alec Vahanian, MD;
Gérard Coppé, MD
Jean Louis Mas, MD on behalf of ECLAT1 Study Investigators
From the Service de Médicine Interne et Hypertension Artérielle (J.A.), CHU Toulouse, Toulouse, France; INSERM U558 (J.A., J.P.C., V.B.), Toulouse, France; Hôpital Sainte Anne (E.T., E.L.M.), Paris, France; Hôpital Bichat (A.V.), Paris, France; Centre Hospitalier (G.C.), Arpajon, France; in private practice (G.J.), Marseille, France.
Correspondence to Jacques Amar, INSERM 558, 37 Allées Jules Guesde, 31073 Toulouse, France. E-mail amar.j{at}chu-toulouse.fr
 |
Abstract
|
|---|
Background and Purpose Hypertension control is a cornerstone
of preventive treatment in patients at risk for cerebral attack.
The aim of this study was to analyze hypertension management
in secondary prevention of stroke as compared with patients
in secondary prevention of myocardial infarction (MI).
Methods The ECLAT1 study was a cross-sectional study conducted in all French regions in a random sample of 3009 practitioners. Patients with a documented history of atherothrombotic disease were included. Risk factors and the last measurement of blood pressure (BP) available in the medical record were noted. In the current study, patients with treated hypertension and a unique manifestation of atherothrombotic disease, ischemic stroke or MI, were analyzed.
Results Among the 4346 patients included in the ECLAT1 study, 1416 patients with treated hypertension and stroke or MI were analyzed. Hypertension control was poorer in patients with stroke as compared with patients with MI (24.56% versus 34.16% P<0.01). Compared with patients with MI, systolic BP (140.61±14.14 versus 144.21±14.99; P<0.0001), pulse pressure (59.91±11.94 versus 62.48±12.49; P<0.001), and, to a lesser extent, diastolic BP (80.69±8.39 versus 81.72±8.85; P<0.05) were higher in stroke patients. Moreover, antihypertensive monotherapy was more frequently used in stroke than in MI patients (43.16% versus 31.44% P<0.0001).
Conclusion With respect to the beneficial influence of tight BP control in secondary prevention of stroke, our results highlight the need for information provided to practitioners to recall the importance of hypertension control in this situation and to increase the use of combination therapy.
Key Words: stroke secondary prevention hypertension
 |
Introduction
|
|---|
Approximately 0.2% of the population of most Western countries
have a stroke each year.
1 Among survivors, 7% have a recurrent
event each year.
2 For these reasons, stroke is expected to remain
the second leading cause of death globally for the next few
decades.
3 Applying the best available evidence-based secondary
prevention strategies to reduce the burden of stroke in the
population is an important public health issue.
4 In this respect,
the continuous relationship between blood pressure and stroke
5 and the positive influence of strict blood pressure (BP) control
in stroke prevention
68 demonstrate that hypertension
control is a cornerstone of preventive treatment in patients
at risk for stroke. In a recent observational study conducted
in tertiary care in a stroke prevention clinic in Canada, 66%
of treated hypertensive subjects in secondary stroke prevention
were controlled at 140/90 mm Hg threshold, and this percentage
increased at 86% after 1-year follow-up.
9 However, data are
lacking on BP control in patients in secondary prevention of
stroke in primary care. The aim of this study was to analyze
hypertension management in patients with previous history of
ischemic stroke in primary care as compared with patients in
secondary prevention of myocardial infarction.
 |
Subjects and Methods
|
|---|
Study Design
The ECLAT1 study was a cross-sectional study conducted in all
French regions in geographic-stratified random sample of 3009
general practitioners (GP). The number of GP by region was closely
related to the distribution of GP in France.
10 The GP performed
their own surveys. The surveys were completed in an anonymous
fashion. All the patients examined at office on December 7,
2000, were eligible. Patients with a documented history of ischemic
stroke, myocardial infarction (MI), or peripheral artery disease
were included. Gender, age, smoking habits, diabetes mellitus,
drug regimens, and cardiovascular history were duly reported.
Height and weight were measured. The last measurement of BP
available in the medical record was noted. Smokers were defined
as patients who currently smoked (cigarettes smoked >1/day)
or who stopped smoking <1 year ago. With respect to the aim
of the study among patients included in the ECLAT1 study, we
analyzed treated hypertensive patients who presented with a
unique manifestation of atherothrombotic disease: MI or ischemic
stroke.
Hypertension Criteria
Controlled hypertension was defined as BP <140/90 mm Hg. Uncontrolled hypertension was defined as BP
140/90 mm Hg. Isolated systolic hypertension was defined as systolic BP
140 mm Hg and diastolic BP <90 mm Hg. Borderline isolated systolic hypertension was defined as 140
systolic BP
160 mm Hg and diastolic BP <90 mm Hg.11
Data Analysis
Patients were categorized according to the localization of their atherothrombotic disease (MI or ischemic stroke) and according to BP control. The analysis of antihypertensive treatment was conducted with respect to the World Health Organization (WHO) guidelines.11 We differentiated monotherapy and combination therapy as treatments comprising 2, 3, or more drugs. The comparisons were performed with
2 test or with Student t test. The relations between clinical characteristics, cardiovascular risk factors, and hypertension control were assessed first in bivariate analysis and then using a multivariate logistic regression. All the variables found to be associated with hypertension control (P<0.10) in bivariate analysis were entered in the model. Also, the model was systematically adjusted for age. Statistical analysis was performed on SAS statistical software (SAS/STAT users guide, release 6.12; SAS Institute Inc).
 |
Results
|
|---|
Among the 5039 GP asked to participate in the survey, 875 (17.36%)
declined and 1155 (22.92%) failed to satisfactorily complete
the questionnaire. Finally, 3009 GP participated in the survey
(participation rate: 59.71%).
Baseline Characteristics
Among the 4346 patients included in the ECLAT1 study, 2614 (60.15%) patients had previous history of hypertension, of whom 129 (2.97%) were not using antihypertensive drug treatment and 1033 (23.76%) had peripheral artery disease or had both stroke and MI. These patients were excluded from the analysis. Data concerning all variables were available for 1416 (32.58%) treated hypertensive patients with a unique manifestation of atherothrombotic disease: 986 with previous history of MI and 670 with previous history of ischemic stroke. These patients formed the basis of this report (Tables 1 and 2
).
BP Control
In the sample, hypertension control was achieved in a lower percentage of patients with stroke than in patients with MI (24.56% versus 34.16% P<0.01) (Table 2). Systolic BP, pulse pressures, and, to a lesser extent, diastolic BP were higher in patients with a previous history of stroke than in patients with MI (Table 2). To take into account the potential influence of age and associated diseases on BP level, we performed subgroup analyses. The difference in BP control between stroke and MI patients remained of similar magnitude in patients above and beyond the median value of age (72 years) and in patients free of heart failure, atrial fibrillation, dementia, cancer, or other severe nonvascular diseases, except in women (Table 3). In bivariate analysis, sex (P=0.0006), heart failure (P=0.008), body mass index (P=0.06), and history of stroke (P=0.0001) were associated with hypertension control whereas atrial fibrillation, treated dyslipidemia, diabetes, associated diseases, antihypertensive strategy, and type of antihypertensive treatment were not (P>0.10). In multivariate logistic regression analysis, stroke was independently associated with a higher risk of uncontrolled hypertension (odds ratio, 1.44; 95% CI, 1.13 to 1.85) (Table 4).
Analysis of Hypertension Management
ß-Blockers, angiotensin-converting enzyme (ACE) inhibitors, diuretics, and calcium channel blockers were the most prescribed drugs in MI and stroke patients, respectively. Compared with MI patients, more patients with stroke were receiving monotherapy (stroke 43.16% versus MI 31.44%; P<0.0001) (Table 2). When focused on uncontrolled hypertension, a quite similar difference was observed: 182/430 (42.33%) of stroke patients were receiving monotherapy versus 183/557 (32.85%) of MI patients (P<0.01). Also, one fifth of MI patients [19.21% (107/557)] and one sixth of stroke patients [16.28% (70/430)] with uncontrolled hypertension were receiving a combination of at least 3 drugs, including a diuretic.
 |
Discussion
|
|---|
The main finding of this study is that BP control in patients
with treated hypertension is poorer after stroke than after
MI. It seems even poorer than previously reported in primary
prevention.
12 In this respect, a large body of evidence has
shown the beneficial effect of strict BP control in stroke prevention.
13 First, the relation between stroke and BP is steeper than the
relation between coronary heart disease and BP: in a landmark
analysis
5 of 9 prospective observational studies, differences
in diastolic BP of 5, 7.5, and 10 mm Hg were, respectively,
associated with a reduction in stroke of at least 34%, 46%,
and 56%, and there was a 21%, 29%, and 37% reduction in coronary
heart disease. Second, in 1997, a meta-analysis
6 of 9 randomized
trials was conducted to assess the effect of antihypertensive
drugs on clinical outcomes in patients with previous stroke;
a 28% reduction in the recurrence of stroke was reported. In
agreement with this finding, a large-scale randomized trial
8 in 2001 showed a similar result: a mean reduction of 9 mm Hg
in systolic BP and 4 mm Hg in diastolic BP with perindopril±indapamide-based
therapy lowered the risk of stroke by 28%. Lastly, a recent
meta-analysis
14 has suggested that reduction in stroke risk
is related to the magnitude of BP reduction. Unfortunately,
although all these data reinforce the importance of strict BP
control in secondary stroke prevention, we found that in general
practice, only 1 of 4 patients with stroke had controlled BP
at the 140/90 mm Hg threshold.
Patient Characteristics
Because the relationship between stroke and BP is steeper than the relationship between MI and BP,5 it is likely that before the occurrence of stroke, uncontrolled hypertension was more prevalent than before the occurrence of MI. In this respect, BP may be poorly controlled in stroke patients because their hypertension is more refractory to treatment. However, this hypothesis cannot be assessed with respect to the cross-sectional design of the study. However, patients with stroke were older and more frequently had a previous history of dementia or atrial fibrillation than MI patients, whereas heart failure, diabetes, and male sex were more prevalent in MI patients. The deleterious influence of age and associated risk factors on BP control has been repeatedly shown.1517 Also, it is likely that heart failure results in a decrease in BP level and helps control hypertension. Lastly, because strict BP control may not be considered as a suitable goal by the GP for patients with short life expectancies, the difference in the prevalence of associated diseases may have contributed to explain the difference in hypertension control between stroke patients and MI patients. To test these hypotheses, we analyzed the differences in BP control between MI patients and stroke patients in various subgroups. In such a condition, the difference in BP control remained significant between MI patients and stroke patients in all subgroups but women. Moreover, in multivariate analysis, after adjustment for sex and other confounders, the probability of being controlled for hypertension remained significantly higher in MI patients as compared with stroke patients. In summary, all these data suggest that patients characteristics in terms of demographic characteristics, associated risk factors, or associated diseases do not fully account for the poorer BP control observed in stroke patients.
Hypertension Management
The second finding of the study is that compared with patients with MI, hypertensive patients with stroke were more frequently treated with a monotherapy. BP level could not explain this difference in the intensity of antihypertensive treatment. Conversely, because hypertensive patients with a history of stroke had higher systolic BP and pulse pressure than hypertensives with a history of MI, one could expect an increase in the intensity of antihypertensive therapy in the former group with respect to the deleterious influence of these parameters on cardiovascular prognosis.18,19 It is likely that the beneficial effects of ß-blockers beyond BP reduction both on outcome20,21 and on relief of angina symptoms22 contribute to the larger use of combination therapy in MI patients. Because of the cross-sectional design of the study, it could not be established to what extent this larger use of combination therapy has accounted for in the better BP control observed in patients with MI. However, international11 and national guidelines23,24 recommend combining drugs when monotherapy fails to control hypertension. Also, it is of interest to note that in a prospective study conducted in primary care older patients, Berlowitz et al25 have shown that patients who received more intensive medical therapy had better hypertension control. Thus, in light of these data, it would be highly relevant to understand the reasons for the lack of more intensive drug therapy in uncontrolled hypertensives with stroke. Interestingly, in a US cross-sectional study on hypertension management,26 conducted in primary care, the most frequently cited reason for no initiation or change in therapy in patients with uncontrolled hypertension was related to the primary care physicians being satisfied with BP. On average, physicians reported that 150 mm Hg was the lowest systolic BP at which they would recommend pharmacologic treatment to patients, compared with 91 mm Hg for diastolic BP. In accordance with this finding, we showed that the majority of patients with uncontrolled hypertension with stroke had isolated systolic hypertension. Therefore, as in primary prevention,27 our data suggest that obtaining strict systolic BP control in stroke patients is not a realistic nor a desirable target in the GP opinion. Concerns about an excessive decrease in BP in patients with severe supra-aortic atherosclerotic lesions28 may explain this attitude. Obviously, this point of view represents a major obstacle to the control of hypertension in stroke secondary prevention. In this respect, it would be useful to provide information to GP to improve the use of combination therapy.
 |
Conclusion
|
|---|
This study provides for the first time to our knowledge data
on hypertension management in secondary prevention of stroke
in a large and representative sample of GP in a Western country.
BP control was poorer and use of combination antihypertensive
therapy was less frequent in patients with a previous history
of stroke as compared with patients with MI. Demographic characteristics
or associated diseases of patients with stroke do not account
for these results. An underestimation of the risk related to
systolic BP and of the benefit drawn from strict BP control
in patients with stroke may explain these findings. Our results
suggest that information should be provided to GP on hypertension
management in secondary stroke prevention to help improve the
prognosis of this population at high risk.
 |
Acknowledgments
|
|---|
The ECLAT1 Study was financially supported by Sanofi-Synthelabo
and Bristol-Myers Squibb.
Received January 15, 2004;
revision received March 1, 2004;
accepted April 1, 2004.
 |
References
|
|---|
- Hankey GJ. Stroke: how large a public health problem, and how can the neurologist help? Arch Neurol. 1999; 56: 748754.[Abstract/Free Full Text]
- Straus SE, Majumdar SR, McAlister FA. New evidence for stroke prevention: scientific review. JAMA. 2002; 288: 13881395.[Abstract/Free Full Text]
- Lopez AD, Murray CC. The global burden of disease, 19902020. Nat Med. 1998; 4: 12411243.[CrossRef][Medline]
[Order article via Infotrieve]
- Hankey GJ, Warlow CP. Treatment and secondary prevention of stroke: evidence, costs, and effects on individuals and populations. Lancet. 1999; 354: 14571463.[CrossRef][Medline]
[Order article via Infotrieve]
- MacMahon S, Peto R, Cutler J, Collins R, Sorlie P, Neaton J, Abbott R, Godwin J, Dyer A, Stamler J. Blood pressure, stroke, and coronary heart disease. Part 1. Prolonged differences in blood pressure: prospective observational studies corrected for the regression dilution bias. Lancet. 1990; 335: 765774.[CrossRef][Medline]
[Order article via Infotrieve]
- Gueyffier F, Boissel JP, Boutitie F, Pocock S, Coope J, Cutler J, Ekbom T, Fagard R, Friedman L, Kerlikowske K, Perry M, Prineas R, Schron E. Effect of antihypertensive treatment in patients having already suffered from stroke. Gathering the evidence. The INDANA (INdividual Data ANalysis of Antihypertensive intervention trials) Project Collaborators. Stroke. 1997; 28: 25572562.[Abstract/Free Full Text]
- Staessen JA, Wang JG, Thijs L. Cardiovascular protection and blood pressure reduction: a meta-analysis. Lancet. 2001; 358: 13051315.[CrossRef][Medline]
[Order article via Infotrieve]
- PROGRESS Collaborative Group. Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6105 individuals with previous stroke or transient ischaemic attack. Lancet. 2001; 358: 10331041.[CrossRef][Medline]
[Order article via Infotrieve]
- Mouradian MS, Majumdar SR, Senthilselvan A, Khan K, Shuaib A. How well are hypertension, hyperlipidemia, diabetes, and smoking managed after a stroke or transient ischemic attack? Stroke. 2002; 33: 16561659.[Abstract/Free Full Text]
- Bongard V, Cambou JP, Coppe G, Jullien G, Vahanian A, Mas JL. [Prevalence and management of patients with a prior history of atherothrombotic disease in primary care in France. Results of the ECLAT1 survey]. Arch Mal Coeur Vaiss. 2003; 96: 833840.In French.[Medline]
[Order article via Infotrieve]
- World Health Organization, International Society of Hypertension Writing Group. 2003 World Health Organization (WHO)/International Society of Hypertension (ISH) statement on management of hypertension. J Hypertens. 2003; 21: 19831992.[CrossRef][Medline]
[Order article via Infotrieve]
- Hajjar I, Kotchen TA. Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 19882000. JAMA. 2003; 290: 199206.[Abstract/Free Full Text]
- Chalmers J, Todd A, Chapman N, Beilin L, Davis S, Donnan G, Frommer M, Huxley R, Lenfant C, MacMahon S, Mancia G, Mendis S, Whitworth J, Zanchetti A; International Society of Hypertension Writing Group. International Society of Hypertension (ISH): statement on blood pressure lowering and stroke prevention. J Hypertens. 2003; 21: 651663.[CrossRef][Medline]
[Order article via Infotrieve]
- Rashid P, Leonardi-Bee J, Bath P. Blood pressure reduction and secondary prevention of stroke and other vascular events: a systematic review. Stroke. 2003; 34: 27412748.[Abstract/Free Full Text]
- Amar J, Chamontin B, Genes N, Cantet C, Cambou JP. Why is hypertension so frequently uncontrolled in secondary prevention? J Hypertens. 2003; 21: 11991205.[CrossRef][Medline]
[Order article via Infotrieve]
- Amar J, Vaur L, Perret M, Bailleau C, Etienne S, Chamontin B, PRATIK Study Investigators. Hypertension in high-risk patients: beware of the underuse of effective combination therapy (results of the PRATIK Study). J Hypertens. 2002; 20: 779784.[CrossRef][Medline]
[Order article via Infotrieve]
- Fagard RH, Van Den Enden M, Leeman M, Warling X. Survey on treatment of hypertension and implementation of World Health Organization/International Society of Hypertension risk stratification in primary care in Belgium. J Hypertens. 2002; 20: 12971302.[CrossRef][Medline]
[Order article via Infotrieve]
- Benetos A, Thomas F, Bean K, Gautier S, Smulyan H, Guize L. Prognostic value of systolic and diastolic blood pressure in treated hypertensive men. Arch Intern Med. 2002; 162: 577581.[Abstract/Free Full Text]
- Benetos A, Rudnichi A, Safar M, Guize L. Pulse pressure and cardiovascular mortality in normotensive and hypertensive subjects. Hypertension. 1998; 32: 560564.[Abstract/Free Full Text]
- Pepine CJ, Cohn PF, Deedwania PC, Gibson RS, Handberg E, Hill JA, Miller E, Marks RG, Thadani U. Effects of treatment on outcome in mildly symptomatic patients with ischemia during daily life. The Atenolol Silent Ischemia Study (ASIST). Circulation. 1994; 90: 762768.[Abstract/Free Full Text]
- Olsson G, Rehnqvist N, Sjogren A, Erhardt L, Lundman T. Long-term treatment with metoprolol after myocardial infarction: effect on 3 year mortality and morbidity. J Am Coll Cardiol. 1985; 5: 14281437.[Abstract]
- Ardissino D, Savonitto S, Egstrup K, Rasmussen K, Bae EA, Omland T, Schjelderup-Mathiesen PM, Marraccini P, Merlini PA, Wahlqvist I, Rehnqvist N; for the IMAGE Study Group. Selection of medical treatment in stable angina pectoris: results of the International Multicenter Angina Exercise (IMAGE) Study. J Am Coll Cardiol. 1995; 25: 15161521.[Abstract]
- Agence Nationale dAccréditation et dEvaluation en Santé. Management of adults with essential hypertensionclinical practice recommendations and economic data. April 2000. The full report (ISBN 2910653-781) is available from Agence Nationale dAccréditation et dEvaluation en Santé, Service Communication et Diffusion, 159 rue nationale or can be downloaded free of charge: http://www.anaes.fr or http://www.sante.fr. Accessed May 10, 2004.
- Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003; 289: 25602572.[Abstract/Free Full Text]
- Berlowitz DR, Ash AS, Hickey EC, Friedman RH, Glickman M, Kader B, Moskowitz MA. Inadequate management of blood pressure in a hypertensive population. N Engl J Med. 1998; 339: 19571963.[Abstract/Free Full Text]
- Oliveria SA, Lapuerta P, McCarthy BD, LItalien GJ, Berlowitz DR, Asch SM. Physician-related barriers to the effective management of uncontrolled hypertension. Arch Intern Med. 2002; 162: 413420.[Abstract/Free Full Text]
- Lloyd-Jones DM, Evans JC, Larson MG, ODonnell CJ, Roccella EJ, Levy D. Differential control of systolic and diastolic blood pressure: factors associated with lack of blood pressure control in the community. Hypertension. 2000; 36: 594599.[Abstract/Free Full Text]
- Rothwell PM, Howard SC, Spence JD. Carotid Endarterectomy Trialists Collaboration. Relationship between blood pressure and stroke risk in patients with symptomatic carotid occlusive disease. Stroke. 2003; 34: 25832590.[Abstract/Free Full Text]
This article has been cited by other articles:

|
 |

|
 |
 
E. Touze, J. Coste, M. Voicu, J. Kansao, R. Masmoudi, B. Doumenc, P. Durieux, and J.-L. Mas
Importance of In-Hospital Initiation of Therapies and Therapeutic Inertia in Secondary Stroke Prevention: IMplementation of Prevention After a Cerebrovascular evenT (IMPACT) Study
Stroke,
June 1, 2008;
39(6):
1834 - 1843.
[Abstract]
[Full Text]
[PDF]
|
 |
|

|
 |

|
 |
 
S. E. Ramsay, P. H. Whincup, S. G. Wannamethee, O. Papacosta, L. Lennon, M. C. Thomas, and R. W. Morris
Missed opportunities for secondary prevention of cerebrovascular disease in elderly British men from 1999 to 2005: a population-based study
J. Public Health Med.,
September 1, 2007;
29(3):
251 - 257.
[Abstract]
[Full Text]
[PDF]
|
 |
|