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(Stroke. 2003;34:2748.)
© 2003 American Heart Association, Inc.

Comments, Opinions, and Reviews

Editorial Comment—Secondary Prevention of Stroke: Beyond Meta-Analyses

Department of Clinical Investigation Centre, Inserm - Hospices Civils de Lyon, Hôpital L Pradel, Lyon, France

An extract of the first 250 words of the full text is provided, because this article has no abstract.

	Introduction

 
Secondary prevention of stroke by blood pressure lowering drugs has been assessed in randomized controlled trials for more than 30 years,¹ but the formal demonstration of a clinical benefit awaited the results from 2 major trials: PATS in 1995² and PROGRESS in 2001.³ Rashid et al have summarized the results from these and other available randomized controlled trials, to assess the effectiveness of these drugs on vascular events. In addition, they address other clinically relevant questions in exploring the heterogeneity between trials, and the relationship between blood pressure fall and risk reduction.

	Overall Benefit

 
Overall, the use of blood pressure-lowering drugs was associated with significant reductions in stroke, myocardial infarction, and total vascular events. Beneficial trends observed for vascular or total mortality were not statistically significant. The methodology of randomized controlled trials allows affirmation that drugs per se provoked these reductions.

	Is Hypertension Needed for Expecting a Benefit From Blood Pressure-Lowering Drugs?

 
The benefit observed in the 4 trials that included participants irrespective of their blood pressure level was of the same magnitude of that observed in the others. This reinforces the results obtained in subgroups from isolated trials,^3,4 strongly advocates the prescription of the evaluated drugs in people without hypertension for the prevention of stroke recurrence, and puts into question the definition of hypertension.

	Which Drug Can Be Used as a First-Line Therapy?

 
Exploring the heterogeneity of results suggested that it could be partially explained by the class of the first-line drug. In particular, the beta blocker atenolol was not associated with any benefit, and ACE inhibitors alone (ramipril and perindopril) reduced only the risk of myocardial infarction. On the contrary, . . . [Full Text of this Article]