Hypertension and Stroke (eBook)

Foreword 7
Preface 9
Contents 11
Contributors 13
Part I Blood Pressure and Hypertension as Antecedents of Stroke 15
1 Blood Pressure: Definition, Diagnosis, and Management 16
Definition of Hypertension 16
Diagnosis of Hypertension 17
Evaluation Goals 17
How to Measure Blood Pressure 17
Evaluation of the Hypertension: Addressing Three Key Questions 18
General Principles of Diagnosis of Hypertension: Medical History 18
General Principles of Diagnosis of Hypertension: Physical Examination 20
Frequency of Blood Pressure Monitoring After the Initial Examination 22
Laboratory Studies in the Evaluation of the Patient with Hypertension or Elevated Blood Pressure 22
Evaluation for Secondary Causes of Hypertension or Elevated Blood Pressure 23
Summary: Evaluation of Elevated Blood Pressure 23
Management of Hypertension and Elevated Blood Pressure 23
Establishing a Goal Blood Pressure for Blood Pressure Control 23
Home Blood Pressure Monitoring 24
Lifestyle Measures 24
Antihypertensive Medication 25
Diuretics: Chlorthalidone and Chlorothiazide, Introductory Year: 1957 (US) 27
Beta-Blockers: Propranolol, Introductory Year: 1964 (UK) 27
Angiotensin-Converting Enzyme (ACE) Inhibitors: Captopril, Introductory Year: 1981 (US) 28
Calcium Channel Blockers: Verapimil/Diltiazem/Nifedipine, Introductory Year: 1981 (US) 28
Angiotensin Receptor Blockers: Losartan, Introductory Year: 1995 (US) 29
Other Blood Pressure-Lowering Agents 29
Devices and Other Methods for Blood Pressure Lowering 29
References 30
2 The Link Between Hypertension and Stroke: Summary of Observational Epidemiological Studies 33
Hypertension as a Risk Factor for Stroke 33
Hypertension as a Risk of Stroke by Stroke Subtype 38
Hypertension and Ischemic Stroke 38
Hemorrhagic Stroke 39
Intracerebral Hemorrhage 39
Subarachonid Hemorrhage 42
Hypertension and Stroke Recurrence 42
Ischemic Stroke Recurrence 42
Hemorrhagic Stroke Recurrence 45
Importance of Systolic Blood Pressure in Elderly 45
Conclusion 46
References 46
3 Blood Pressure Control and Primary Prevention of Stroke: Summary of Clinical Trial Data 52
Introduction 52
Clinical Trials Involving Placebo or No Treatment 53
Clinical Trials Comparing Two or More Active Antihypertensive Drugs 58
Blood Pressure Lowering: Relationship to Primary Stroke Prevention 64
Conclusions 66
References 67
Part II Mechanisms of Hypertension and HypertensionRelated Stroke 71
4 Mechanisms Underlying Essential Hypertension: Neurogenic and Nonneurogenic Contributors 72
Overview 72
The Sympathetic Nervous System and Hypertension 73
Higher Nervous System Regulators of Blood Pressure 74
The Renin--Angiotensin System and Hypertension 75
Nitric Oxide and Hypertension 77
Reactive Oxygen Species and Hypertension 78
20-Hete 79
Summary 81
References 81
5 Pathophysiology and Mechanisms Whereby Hypertension May Cause Stroke 86
Effects of Hypertension on Cerebral Blood Vessels 86
Atherosclerosis 86
Fibrinoid Necrosis and Lipohyalinosis 88
Cerebral Autoregulation 89
Neurovascular Coupling 90
Mechanisms of Ischemic Stroke or Tia in Terms of Hypertension 91
Large Artery Disease 91
Thrombosis 91
Artery-to-Artery Embolism 92
Branch Atheromatous Disease 92
Small Vessel Occlusive Disease 93
Cardioembolism 94
Hypoperfusion 94
Mechanisms of Intracranial Hemorrhages in Terms of Hypertension 95
Hypertensive Intracerebral Hemorrhage 95
Chronic Hypertension 96
Acute Hypertension 96
Aneurysmal Subarachnoid Hemorrhage 97
Mechanisms of Silent Brain Lesions in Terms of Hypertension 98
White Matter Lesions 98
Silent Infarctions 99
Cerebral Microbleeds 99
Conclusions 100
References 100
Part III Management of Blood Pressure for First Stroke Prevention, Immediately after Acute Stroke, and for Recurrent Stroke Prevention 104
6 Cardiovascular Risk Assessment and Summary of Guidelines for the Management of Hypertension 105
Introduction 105
Hypertension and Cardiovascular Disease 106
Guidelines for the Management of Hypertension 110
Guideline Treatment Goals 110
Pharmacological Therapy 113
Guideline Updates and JNC 8 115
References 117
7 Acute Blood Pressure Management After Ischemic Stroke 122
Introduction 122
Hypertension in Acute Ischemic Stroke 123
Incidence and Natural History 123
Mechanisms of Early Hypertension in Acute Ischemic Stroke 123
Effect of Hypertension on Outcome 123
Mortality 123
Stroke Progression 124
Hemorrhagic Transformation 124
Coexisting Conditions 124
Cerebrovascular Pathophysiology 124
Normal Cerebrovascular Physiology 124
Effect of Chronic Hypertension on Cerebral Blood Flow and Autoregulation 125
Cerebral Blood Flow and Autoregulation in Acute Cerebral Ischemia 125
Acute Treatment of Hypertension after Ischemic Stroke 125
The Controversy 125
Effect on Cerebral Blood Flow 126
Effect on Neurological or Functional Outcome 128
Case Studies 128
Randomized Clinical Trials 128
Guidelines for BP Management in Acute Ischemic Stroke 131
Choice of Antihypertensive Agents 131
Conclusion 132
References 132
8 Hypertensive Encephalopathy and Acute Blood Pressure Management After Hemorrhagic Stroke 134
Introduction 134
Hypertensive Encephalopathy 134
Historical Overview 134
Epidemiology 135
Clinical 135
Pathophysiology 136
Workup 137
Magnetic Resonance Imaging 137
Posterior Reversible Encephalopathy Syndrome 137
Treatment 138
Summary 141
Acute Blood Pressure Management After Hemorrhagic Stroke 141
Epidemiology 141
Clinical 141
Controversy: To Treat or not to Treat 142
Clinical Trials 143
Guideline Recommendations 144
Summary 145
References 145
9 Recurrent Stroke Prevention I: Diuretic and Angiotensin-Converting Enzyme Inhibitors (ACEIs) The PROGRESS Trial 149
Background to the Progress Study 149
Perindopril and Indapamide 151
Design of the Progress Trial 153
Organization 153
Implementation of the Trial 153
Results 154
Context and Interpretation 159
References 161
10 Recurrent Stroke Prevention II: Angiotensin Receptor BlockersThe LIFE, MOSES, PRoFESS, and Other Trials 164
Introduction 165
The ReninAngiotensin System and Pharmacology of Angiotensin Receptor Blockers 165
The Clinical Effects of ARBs 166
Effect on Hypertension 166
First and Recurrent Stroke Prevention Trials 166
Life 166
Ontarget 167
Transcend 168
Moses Trial 169
Profess 169
Pooled Analysis of Profess and Transcend 170
Access 170
Effect on Cardiovascular Disease and Nephropathy 171
Cardiovascular Disease 171
Should ARBs Be First-Line Agents for Stroke Prevention 173
Other Potential Uses of ARBs 173
Atrial Fibrillation 173
Vascular Cognitive Impairment 173
References 174
11 A Practical Guide to Recurrent Stroke Prevention 177
Introduction 177
Overview of Stroke Subtypes and Risk Factors 177
Classification by Stroke Subtype and Epidemiology 177
Risk Factors 178
Intracerebral Hemorrhage 178
Transient Ischemic Attack 179
Etiology-Specific Interventions in Specific Stroke Subtypes 182
Cardioembolic Stroke 182
Large-Vessel Extracranial Atherothrombotic Disease 184
Intracranial Atherothrombotic Disease 185
Arterial Dissection 185
Intracerebral Hemorrhage 186
Non-Etiology-Specific Interventions and Risk Factor Modification 186
Hypertension 187
Antithrombotic Therapy 187
Dyslipidemia 188
Diabetes Mellitus 189
Hormone Replacement Therapy 190
Tobacco Use 190
Alcohol Use 190
Physical Activity 190
Conclusion 191
References 191
Part IV Mechanisms and Sequelae of Elevated Blood Pressure on Brain Function and Cognition 197
12 Vascular Cognitive Impairment and Alzheimer Disease: Are These Disorders Linked to Hypertension and Other Cardiovascular Risk Factors 198
Introduction 198
Pathophysiologic Mechanisms and Epidemiological Evidence 199
Hypertension, VCI, and AD 199
Other Cardiovascular Risk Factors, VCI, and AD 202
Diabetes Mellitus and Insulin 202
B Vitamins and Homocysteine 203
Metabolic Syndrome, Body Mass Index, and Related Factors 203
Cholesterol 204
Diet and Related Factors 205
Hormonal Factors 205
Exercise and Other Lifestyle Factors 206
Inflammation and Nonsteroidal Anti-inflammatory Drugs 206
Possible Novel or Emerging Factors 207
Conclusion 207
References 207
13 Cerebral Small Vessel Disease, Hypertension, and Cognitive Function 214
Introduction 214
Pathophysiology of Small Vessel Disease 214
Hypertension and Small Vessel Disease 215
White Matter Hyperintensities and Cognition 215
Pattern of Cognitive Dysfunction in Patients with White Matter Hyperintensities 216
Location of White Matter Hyperintensities and Cognition 216
Volume of White Matter Hyperintensities and Cognition 217
Lacunar Infarction and Cognition 218
Basal Ganglia and the Thalamus and Cognition 218
Small Vessel Disease and Mood 220
Hypertension and Cognitive Dysfunction 220
Cross-Sectional Studies 221
Longitudinal Observational Studies 221
Randomized Placebo-Controlled Clinical Trials 222
Conclusions 224
References 224
14 Cerebral Microbleeds, Small-Vessel Disease of the Brain, Hypertension, and Cognition 228
Introduction 228
Cerebral Microbleeds in Specific Cerebral Small-Vessel Diseases 229
Cerebral Microbleeds in Hypertension-Related Vasculopathy and Cerebrovascular Disease 230
Cerebral Microbleeds in CAA 230
Cerebral Microbleeds in CADASIL 231
Specialized Methods for Improved Detection of Cerebral Microbleeds 232
Microbleeds in Population-Based Studies: the Role of Location 232
Cerebral Microbleeds and Clinical Impairment 233
Microbleeds, Hypertension, and Cognition 234
References 235
15 Imaging Effects of Hypertension on the Brain: A Focus on New Imaging Modalities and Options 239
Introduction 239
Effects of Hypertension on the Brain 240
Effects of Hypertension on Cerebral Vasculature 240
Effects of Hypertension on Cerebral Tissue Integrity 240
Effects of Hypertension on Cerebral Function and Metabolism 241
Computed Tomography 241
General Principles 241
Uses in Assessment of the Effects of Hypertension 242
CT Perfusion 242
CT Angiography 242
General Advantages 242
General Disadvantages 243
Magnetic Resonance Imaging 243
General Principles 243
Uses in Assessment of the Effects of Hypertension 243
Magnetic Resonance Angiography 244
MR Perfusion-Weighted Imaging 245
General Advantages 245
General Disadvantages 246
Functional MRI 246
General Principles of BOLD FMRI 246
Uses 247
General Advantages 248
General Disadvantages 248
Diffusion Tensor MR Imaging 248
General Principles 248
Uses and Measures 249
General Advantages and Disadvantages 250
Arterial Spin Labeling 250
General Principles and Technique 251
Uses and Measures 251
General Advantages 251
General Disadvantages 252
Positron Emission Tomography and Single Photon Emission Computerized Tomography 252
General Principles and Technique 252
Uses and Measures 252
General Advantages 253
General Disadvantages 254
Summary and Conclusions 254
References 254
Part V Organization of Stroke Care 258
16 The Joint Commissions Initiatives to Improve Stroke Care and What It Means for Acute Stroke Care and Prevention 259
Introduction 259
The Foundations of Stroke Center Certification 260
Primary Stroke Center Certification Elements 260
Data Compliance with Joint Commission Metrics 262
Growth Rate, Impact, and Current Status of Primary Stroke Center Certification 262
Impact of Primary Stroke Center Certification 263
Current Trends 265
Future Directions for Care Integration: Alexian Brothers Stroke Nurse Navigator Program 266
Quality Improvement of Hypertension Control in Stroke Patients 267
Conclusion 267
References 267
Index 269