Longevity
Going lower on blood pressure helps stroke survivors but not diabetic patients, trials find
By Life and Health Today Staff, . Life and Health Today.
Aiming for a systolic blood pressure (the top number in a reading) below 120 mm Hg, rather than the standard target of below 140, cut the combined risk of death and major cardiovascular events in people who had already had a stroke, according to a large Brazilian trial published in the New England Journal of Medicine. The same strategy, tested in a separate trial of people with type 2 diabetes and published in the same journal, produced no such benefit.
Both trials were presented Saturday at the American Heart Association's scientific sessions in Chicago.
What the stroke trial found
The OPTIMAL-STROKE study, led by Gisele Sampaio of the Federal University of Sao Paulo in Brazil, enrolled people who had survived a stroke and were already on blood pressure medication. Over four years, those whose treatment was intensified to reach a systolic reading below 120 were significantly less likely to die or experience a major cardiovascular event, compared with those managed to the standard threshold of below 140. Non-fatal events counted in the analysis included heart attack, recurrent stroke, and hospitalization for chest pain or heart failure.
Otavio Berwanger of Imperial College London, who chaired the OPTIMAL study steering committee, noted that while there was no increase in end-stage kidney disease, dialysis need, or deaths from kidney causes, some markers of kidney function shifted during the trial, and electrolyte levels changed in ways consistent with diuretic use. Achieving the lower target, he said, requires medical supervision and monitoring of kidney function.
What the diabetes trial found
The OPTIMAL-DIABETES trial, also out of Brazil and also published in the New England Journal of Medicine, asked the same question in a different population. Karla Santo of Einstein Hospital Israelita in Sao Paulo reported that among patients with type 2 diabetes, pushing the systolic target below 120 rather than below 140 did not reduce major cardiovascular events or deaths. The result was neutral.
Shawna Nesbitt of UT Southwestern Medical Center, commenting on the findings, pointed to differences between men and women and between younger and older patients across the OPTIMAL trials and earlier hypertension research. "I think it very strongly suggests that this trial supports rather than rebukes what we already have seen in other trials treating hypertension more aggressively in patients with diabetes," she said, according to STAT News. "We might begin to think about blood pressure treatment in a more nuanced way. That is to say, perhaps we've been lumping patients together in a way that may not necessarily always be advantageous."
A cheaper drug, tried earlier after stroke
A third, smaller trial called REDUCE, led by Jordana Cohen of the Perelman School of Medicine at the University of Pennsylvania, tested a different approach: giving spironolactone, a common and inexpensive diuretic (a drug that helps the body shed fluid), immediately after a stroke rather than waiting until several other medications had failed. Patients who received it early were more likely to reach a blood pressure below 130/80 mm Hg at three months than those receiving standard post-stroke care. The trial was presented as a conference abstract and has not been published in a peer-reviewed journal, which means it has not yet gone through full independent review.
Cohen noted that the trial was designed to measure blood pressure reduction, not cardiovascular outcomes directly. She pointed to existing data showing that a drop of as little as 7 mm Hg in blood pressure has been associated with a 38 percent lower risk of recurrent stroke, though that figure comes from prior research, not from REDUCE itself.
Bruce Ovbiagele of the UCSF Weill Institute for Neurosciences called the approach promising, noting that roughly one in three stroke patients never reaches blood pressure targets, and that about one in five has stopped taking their blood pressure medication within a year of their stroke.
The practical problem
Several researchers at the briefing flagged a challenge that sits outside the data: who is actually responsible for managing blood pressure after a stroke. Ovbiagele described post-stroke care as "very fragmented," with neurologists handling the hospital stay and primary care physicians taking over afterward, leaving questions about when a nephrologist (a kidney specialist) should be involved. Cheryl Bushnell of Wake Forest University put it plainly: "It's not the what, but it's the how."
For anyone with a history of stroke or a diagnosis of type 2 diabetes, these findings are worth raising with the clinician who manages their blood pressure, since the right target may depend on individual history in ways these population-level trials cannot resolve.
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