Optimal Systolic Blood Pressure Levels for Primary Prevention of Stroke in General Hypertensive Adults: Findings From the CSPPT (China Stroke Primary Prevention Trial)

Positive genetic effect of hypertension family history on stroke: A cross Mendelian randomization study

BACKGROUND

Clinical observational study demonstrated that hypertension is an independent risk factor for stroke. Furthermore, both hypertension and stroke exhibit genetic predispositions. However, the genetic relationship between hypertension and stroke in first-degree relatives remains unclear.

METHOD

The Genetic effects were validated using an across-Mendelian randomization (MR) approach. The Genome-Wide Association Study summary data used in this study were obtained from a publicly available platform. The primary MR effect employed was inverse-variance weighted (IVW), and the other analysis methods included MR-Egger, weighted median, simple mode, and weighted mode. Prior to MR analysis, tests for MR_PRESSO, pleiotropy, and heterogeneity were conducted.

RESULT

The presence of family history of hypertension significantly contributed to the genetic predisposition to various types of stroke, including ischemic stroke, subarachnoid hemorrhage, lacunar stroke, cardioembolic ischemic stroke, small vessel ischemic stroke, and large artery atherosclerosis-related ischemic stroke.

CONCLUSION

Briefly, hypertension in first-degree relatives has a genetic impact on the risk of stroke development. Shared genetic factors may exist between hypertension and stroke.

Multi-dimensional analyses of the associations between depression, nocturnal awakening and asthmatic outcomes

BACKGROUND

Depression plays an important role in the occurrence and development of asthma. Nocturnal awakening secondary to asthma is a crucial sign of the deterioration of asthmatic outcomes. This study plans to determine the associations between depression, nocturnal awakening and asthmatic outcomes by using multi-dimensional analyses.

METHODS

Study population came from the Adult Asthma Call-Back Survey 2013-2017. Multivariable regression analysis with binomial or Poisson models, dose-dependent analysis and mediation analysis were used to explore the associations between depression and nocturnal awakening with asthmatic episodes/attacks, emergency room (ER) and hospital visits.

RESULTS

18,684 physician-diagnosis asthmatics were included into this study. This population consisted of 31.4 % with nocturnal awakening and 37.6 % with depression. Multivariable binomial analyses suggested that nocturnal awakening and depression were positively associated with asthmatic episodes/attacks and ER visits. Dose-dependent analyses demonstrated that the increase of nocturnal awakening was positively associated with the increase of depression and three asthmatic outcomes. Asthmatics with depression had the higher prevalence (adjusted OR = 1.17, 95%CI: 1.08-1.27) and frequency (adjusted RR = 1.08, 95%CI: 1.07-1.10) of nocturnal awakening than those without depression. Mediation analyses suggested that clarification of verbiage denoted trivial effect of depression on the associations between nocturnal awakening with asthmatic outcomes, while nocturnal awakening mildly mediated these associations between depression with asthmatic episodes/attacks (15.26 %, 95%CI: 7.29 %-28.7 %) and ER visits (13.29 %, 95%CI: 5.33 %-44.12 %).

LIMITATION

The cross-sectional nature limited inferences on causality.

CONCLUSIONS

Our findings showed that depression and nocturnal awakening might affect asthmatic outcomes. Nocturnal awakening harbored the mediated effect in the correlations between depression and asthmatic outcomes.

Associations of siesta and total sleep duration with hypertension or cardiovascular diseases in middle-aged and older adults

BACKGROUND

Whether the ratio of siesta duration in the total sleep duration was associated with the occurrence of hypertension or cardiovascular diseases (CVDs) was unclear.

HYPOTHESIS

To explore the associations of siesta, and siesta ratio with hypertension or CVDs in middle-aged and older adults.

METHODS

This cohort study collected the data of 9247 middle-aged and older adults. The associations of siesta, and siesta ratio with hypertension were analyzed in 7619 participants while the associations of siesta, and siesta ratio with CVDs were analyzed in 8685 participants via univariate and multivariate logistic regression analysis.

RESULTS

Total sleep duration < 6 h (odd ratio [OR] = 1.168, 95% confidence interval [CI]: 1.023-1.335) and siesta ratios ≥ 0.4 (OR = 1.712, 95% CI: 1.129-2.594) were associated with increased risk of hypertension in middle-aged and older adults. Siesta ratio ≥ 0.4 was linked with higher risk of hypertension in males aged ≥ 60 years and total sleep duration < 6 h was correlated with elevated risk of hypertension in males < 60 years. The risk of CVDs was elevated in people with siesta duration < 0.5 h (OR = 2.053, 95% CI: 1.323-3.185). In females ≥60 years, the sleep duration at night < 6 h was associated with increased risk of CVDs. In females < 60 years, increased risk was observed in those with siesta duration < 0.5 h and sleep duration at night < 6 h.

CONCLUSION

Short sleep duration or high siesta ratio were associated with higher risk of hypertension. Short siesta duration, sleep duration at night or total sleep duration were correlated with an elevated risk of CVDs.

Effect of baseline resting heart rate on the risk of all-cause death in Chinese patients with hypertension

The aim of this study was to investigate the association between baseline resting heart rate (RHR) and all-cause death in the China Stroke Primary Prevention Trial (CSPPT). A post hoc analysis was conducted using data from 20,648 hypertensive adults without cardiovascular disease in the CSPPT and with baseline RHR data available. Over a median follow-up duration of 4.5 years, the baseline RHR and risk for all-cause death had a nonlinear relationship. The risk of all-cause death was higher in participants with an RHR ≥85 bpm (hazard ratio 1.42; 95% confidence interval 1.03-1.96, p = .031) than in those with a baseline RHR of 75-80 bpm. The effect of RHR on all-cause death during the treatment period was modified by the folate level (p = .020) and systolic blood pressure (SBP) during treatment(p = .056). The effect of RHR on the risk of all-cause death was stronger when the folate level was low than when it was high; the risk was higher when the RHR was < 75 bpm or ≥80 bpm than when it was 75-80 bpm. RHR had a greater effect on the risk of all-cause death when SBP during treatment was well controlled than when it was not; again, the risk was higher when the RHR was < 75 bpm or ≥80 bpm than when it was 75-80 bpm. A higher baseline RHR resulted in an increased risk of all-cause mortality in Chinese adults with hypertension but no history of stroke or myocardial infarction.

Role of no table salt on hypertension and stroke based on large sample size from National Health and Nutrition Examination Survey database

Background

To assess the associations between no table salt and hypertension or stroke.

Methods

The data of 15,352 subjects were collected from National Health and Nutrition Examination Survey (NHANES) database. All subjects were divided into no hypertension or stroke group (n = 10,894), hypertension group (n = 5888), stroke group (n = 164) and hypertension and stroke group (n = 511). Univariate and multivariate logistic regression analysis was used to measure the associations of salt type used with hypertension and stroke and co-variables were respectively adjusted in different models.

Results

After adjusting age and gender, other salt intake was associated with 1.88-fold risk of hypertension (OR = 1.88, 95%CI: 1.44–2.46) and no table salt was associated with 1.30-fold risk of hypertension (OR = 1.30, 95%CI: 1.15–1.47). After adjusting age, gender, race, BMI, PIR, marital status, CVDs, whether doctors’ told them to reduce salt, and diabetes, the risk of hypertension was 1.23-fold increase in no table salt group (OR = 1.23, 95%CI: 1.04–1.46). After the adjustment of age and gender, the risk of hypertension and stroke was 3.33-fold increase (OR = 3.33, 95%CI: 2.12–5.32) in other salt intake group and 1.43-fold increase (OR = 1.43, 95%CI:1.17–1.74) in no table salt group.

Conclusion

Other salt intake or no table salt were associated with a higher risk of hypertension or hypertension and stroke.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13722-8.

Plasma selenium and the risk of first stroke in adults with hypertension: a secondary analysis of the China Stroke Primary Prevention Trial

BACKGROUND

Previous studies have indicated that selenium (Se) may play an important role in cardio-cerebrovascular disease. However, the relation between circulating selenium and risk of first stroke remains inconclusive.

OBJECTIVES

We conducted a secondary analysis of the China Stroke Primary Prevention Trial (CSPPT), using a nested case-control design, and aimed to investigate the correlation between Se concentration and first stroke risk in adults with hypertension and examine the potential effect modifiers.

METHODS

In the CSPPT, a total of 20,702 adults with hypertension were randomly assigned to a double-blind daily treatment with either 10 mg enalapril and 0.8 mg folic acid or 10 mg enalapril alone. A total of 618 first stroke cases and 618 controls matched for age, sex, treatment group, and study site were included in this study.

RESULTS

During a median follow-up duration of 4.5 y (IQR: 4.2-4.6 y), there was a significant inverse association between plasma Se and the risk of first stroke (per SD increment; adjusted OR: 0.81; 95% CI: 0.68, 0.96) and ischemic stroke (per SD increment; adjusted OR: 0.76; 95% CI: 0.62, 0.93). Furthermore, a stronger inverse association between plasma Se and first stroke was observed in participants with higher folate concentrations at baseline [≥7.7 ng/mL (median), adjusted OR: 0.67; 95% CI: 0.54, 0.85, compared with <7.7 ng/mL, adjusted OR: 0.98; 95% CI: 0.80, 1.21; P-interaction = 0.008] and those with higher time-averaged systolic blood pressure (SBP) over the treatment period (≥140 mm Hg, adjusted OR: 0.71; 95% CI: 0.58, 0.86, compared with <140 mm Hg, adjusted OR: 0.96; 95% CI: 0.77, 1.20; P-interaction = 0.023).

CONCLUSIONS

There was a significant inverse association between plasma Se and risk of first stroke in Chinese adults with hypertension, especially among those with higher baseline folate concentrations and those with higher time-averaged SBP over the treatment period. This trial was registered at clinicaltrials.gov as NCT00794885.

Does irradiation for initial primary lung cancer affect the risk of metachronous second primary lung cancer?

Several studies have reported inconsistent results about second primary lung cancer (SPLC) after irradiation for initial primary lung cancer (IPLC). The present study aims to assess the effect of ionising radiation on the risk of SPLC. The study population came from SEER database, and included a population-based cohort of 21,397 individuals diagnosed with IPLC between 2004 and 2009 who survived more than 7 years after the initial diagnosis. The first aim was to estimate the risk of SPLC in different periods and the cumulative risk of SPLC. Subsequently, a generalized additive model with Poisson regression analysis and a proportional sub-distribution hazard model was used to determine whether radiation affected the risk of SPLC. Until Dec 2016, there were 488 individuals who developed SPLC, 5368 individuals who died, and there were 15,541 alive individuals, respectively. The risk of SPLC was found to gradually decline with the extent of follow-up time. Age and histology were the two main risk factors of developing SPLC in Poisson regression and competing risk analyses. In Poisson regression analysis, radiation had no significant effect on the risk of developing SPLC (adjusted OR = 0.80, 95% CI 0.54, 1.19, P = 0.28). When considered competing risk of all-cause death, the risk of SPLC in the radiation group was similar to that in the non-radiation group (adjusted sHR = 0.80, 95% CI 0.56, 1.13, P = 0.21). The risk of SPLC was different during different follow-up time. Irradiation for IPLC seemingly did not affect the risk of developing SPLC.

Intracoronary Imaging Versus Coronary Angiography to Guide Drug-Coated Balloon Intervention in Coronary Artery Disease: A Propensity-Matched Pilot Study Analysis

Limited data exist about the effect of intracoronary imaging (ICI)-guided drug-coated balloon (DCB) intervention on clinical end points. In all, 1157 patients with coronary artery disease treated with DCB between December 2014 and December 2017 at Beijing Anzhen Hospital were included in the final analysis in this cohort study. The primary end point was the incidence of target lesion failure (TLF), a composite of cardiac death, target vessel myocardial infarction (MI), and target lesion revascularization, and the key secondary end point was the incidence of cardiac death or target vessel MI. The median follow-up for clinical events was 32.0 months (IQR 25.0-40.0). Intracoronary imaging was used in 90 (7.8%) patients. There was no statistically significant difference in TLF (12.2% vs 12.5%, P = .80) between ICI-guided and angiography-guided group. Cardiac death or target vessel MI rates (1.1% vs 3.7%, P = .17) were numerically lower for the ICI-guided cohort. In the propensity score-based analysis, TLF (10.5% vs 16.2%, P = .19) and cardiac death or target vessel MI rates (1.2% vs 2.3%, P = .51) tended to be lower for the ICI-guided cohort. In this observational study, TLF rate tended to decrease in the ICI-guided DCB treatment group compared with angiography-guided procedures. Larger studies are needed.

Association of visit-to-visit variability in blood pressure and first stroke risk in hypertensive patients with chronic kidney disease

OBJECTIVE

Data on the association between visit-to-visit variability (VVV) in blood pressure (BP) and the risk of stroke among hypertensive patients with chronic kidney disease (CKD) is limited. We aimed to evaluate the relation of VVV in BP with the risk of stroke, and examine any possible effect modifiers in hypertensive patients with mild-to-moderate CKD.

METHODS

This is a post-hoc analysis of the China Stroke Primary Prevention Trial. A total of 3091 patients with estimated glomerular filtration rate 30-60 ml/min per 1.73 m and/or proteinuria at baseline, without occurring stroke and with BP measurements of at least two visits from randomization to the 12-month visit were included. The main VVV in BP was expressed as SD. The primary outcome was first stroke.

RESULTS

The median subsequent treatment duration was 3.7 years. After multivariable adjustment, including baseline SBP and mean SBP during the first 12-month follow-up, there was a significantly positive relationship of SD SBP with the risk of subsequent first stroke (per SD increment; odds ratio, 1.41; 95% confidence interval: 1.17-1.69) and first ischemic stroke (odds ratio, 1.55; 95% confidence interval: 1.26-1.90). Results were consistent across various subgroups, including age, sex, baseline SBP, treatment compliance, and mean SBP, concomitant usage of calcium channel blocker during the first 12-month follow-up period. Similar trends were also found for coefficient of variation SBP, and SD or coefficient of variation DBP. However, there was no significant association between BP variability and first hemorrhagic stroke.

CONCLUSION

In hypertensive adults with mild-to-moderate CKD, visit-to-visit variability in BP was significantly associated with the risk of subsequent first stroke.

Hypertension and stroke in Asia: A comprehensive review from HOPE Asia

Stroke is the primary cause of disability and vascular death worldwide, including Asia. Asian characteristics that differ from the West lead to higher stroke incidence. Stroke epidemiology studies in Asia have shown varying levels of mortality, incidence, prevalence, and burden of disease. Hypertension is the most prevalent risk factor found in Asia. Besides ethnicity that is associated with stroke incidence, both systolic blood pressure, diastolic blood pressure, and blood pressure variability are positively correlated with stroke incidence. Post-stroke cognitive impairment is one of the sequelae that affect one-third of stroke survivors and has become a significant public health concern that is often neglected despite its increasing prevalence. Therefore, it is very important to prevent recurrence by treating stroke optimally and effectively. Increasing awareness and treatment adherence to hypertension, the leading risk factor for stroke, became the main goal in several countries in Asia.

Association of outdoor air pollution with the medical expense of ischemic stroke: The case study of an industrial city in western China

Ischemic stroke, the most frequent cause of severe disability, imposes a significant mental and economic burden on patients and their families. There is increasing evidence to indicate that air pollution contributes to the risk of ischemic stroke. This study aimed to examine the correlation between air pollution and the expense imposed by an ischemic stroke. Data were obtained from hospitals and environmental monitoring stations in an industry city, Longspring, in western China. We used a generalized additive model to estimate the associations between the two factors, measured during 2015-2017. Counter-intuitively, the medical expenses arising from ischemia were negatively associated with the level of air pollution. The corresponding ER for per interquartile range increase of PM2.5, PM10, SO₂ , and NO₂ in lag10 was -0.17% (95% confidence interval (95% CI -0.31%, -0.03%), -0.11% (95% CI -0.2%, -0.02%), -1.04% (95% CI -1.92%, -0.17%) and -0.44% (95% CI -0.66%, -0.22%), respectively (p < 0.05). Subgroups based on gender, age, and season were considered in the analysis. The results indicated that pollutants had significant effects on ischaemia's medical expenses, which were stronger for older people, patients who survived, and warm seasons. This study is the first step in optimizing medical resources, which are essential for policymaking and service planning.

Impact of the 2017 ACC/AHA guideline on the prevalence of elevated blood pressure and hypertension: a cross-sectional analysis of 10 799 individuals

OBJECTIVES

To assess the effect of the 2017 American College of Cardiology and the American Heart Association (ACC/AHA) hypertension guideline on the prevalence of elevated blood pressure (BP) and hypertension and the initiation of antihypertensive treatment, as well as the level of adherence to the BP target in the Saudi population.

DESIGN

A cross-sectional study.

PARTICIPANTS

A total of 10 799 adults (≥18 years old), with three BP readings during 2017-2020 from the Saudi Biobank was used.

PRIMARY OUTCOME

Hypertension was defined using three sources: the Joint National Committee 7 Blood Pressure Guideline (JNC-7) guideline (systolic BP (SBP)≥140 or diastolic BP (DBP)≥90 mm Hg), the 2017 ACC/AHA guideline (SBP≥130 or DBP≥80 mm Hg) and a self-reported hypertension diagnosis.

RESULTS

The prevalence of hypertension, according to the JNC-7 guideline, was 14.49% (95% CI 14.37 to 14.61), and the 2017 ACC/AHA, 40.77% (95% CI 40.60 to 40.94), a difference of 26.28%. Antihypertensive medication was recommended for 24.84% (95% CI 24.69 to 24.98) based on the JNC-7 guideline and 27.67% (95% CI 27.52 to 27.82) using the 2017 ACC/AHA guideline. Lifestyle modification was recommended for 13.10% (95% CI 12.47 to 13.74) of patients with hypertension who were not eligible for a pharmacological intervention, based on the 2017 ACA/AHA guideline. For patients with prescribed antihypertensive medication, 49.56% (95% CI 45.50 to 53.64) and 27.81% (95% CI 24.31 to 31.59) presented with a BP reading above the treatment goal, based on the 2017 ACA/AHA and JNC-7 guidelines, respectively. Using the two definitions, the risk factors were older age, male gender, diabetes diagnosis, increased body mass index, waist circumference and waist-to-hip ratio.

CONCLUSIONS

According to the 2017 ACC/AHA guideline, the prevalence of hypertension has increased significantly, but there was only a small increase in the proportion of patients recommended for antihypertensive treatment. A large proportion of patients with prescribed antihypertensive medication, had a BP above the target. Unless public health prevention efforts are adopted, the increased prevalence of elevated BP and hypertension will increase cardiovascular disease.

Effect of the baseline pulse wave velocity on short term and long term blood pressure control in primary hypertension

OBJECTIVES

Arterial stiffness may affect antihypertensive response to antihypertensive treatment. However, sufficient clinical evidence is lacking. This longitudinal study aimed to evaluate the effect of baseline arterial stiffness measured by the brachial-ankle pulse wave velocity (baPWV) on response to short-term and long-term enalapril-based treatment in 3310 hypertensive adults from the China Stroke Primary Prevention Trial (CSPPT).

METHODS AND RESULTS

Blood pressure (BP) measured at three months (short-term) in 2780 subjects, and the time-average on-treatment BP in 3310 subjects during a median of 4.5-year follow-ups (long-term) were analyzed in the study. After short-term antihypertensive treatment, every 1 m/s increase in baPWV denoted a 7% and 6% decreased chance of achieving systolic BP (SBP) control (odds ratio (OR), 0.93; 95% CI 0.90, 0.96; P < 0.001) and BP control (OR, 0.94; 95% CI 0.91, 0.97; P < 0.001), respectively, after adjustment for age, gender and other variables. After long-term treatment, every 1 m/s increase in baPWV posed an 7% and 6% greater risk of failing to attain SBP control (OR, 0.93; 95% CI 0.90, 0.95; P < 0.001) and BP control (OR, 0.94; 95% CI, 0.92, 0.96; P < 0.001), respectively, not regarding for DBP control after both short- and long-term treatment. Higher baseline baPWV significantly decreased SBP reduction both after three months and the median 4.5-year treatment, while increased DBP reduction after the median 4.5-year treatment.

CONCLUSIONS

Elevated baseline baPWV significantly decreased BP response to short-and long-term treatment in adults with primary hypertensive. Arterial stiffness improvement may be an essential target to achieve adequate BP control.

Positive relationship of hypertensive retinopathy with carotid intima--media thickness in hypertensive patients

OBJECTIVES

We aimed to explore the relationship of hypertensive retinopathy with carotid intima--media thickness (CIMT), and to examine the possible effect modifiers in Chinese adults with hypertension.

METHODS

We conducted a cross-sectional study of 12 342 hypertensive patients with complete exit site visit data from the China Stroke Primary Prevention Trial. CIMT was measured by carotid ultrasonography. Hypertensive retinopathy was diagnosed according to the Keith--Wagener--Barker classification.

RESULTS

The mean (SD) CIMT among study participants was 739.9 (111.4) μm. Compared with patients with grade 1 hypertensive retinopathy or without hypertensive retinopathy, a significantly higher CIMT level (β, 7.63, 95% CI: 2.54--12.73) was observed in patients with grade 2-4 hypertensive retinopathy. Moreover, the association between hypertensive retinopathy (grade 2-4 versus grade 1 or normal) and CIMT was stronger in participants of younger age (<60 years; β, 13.70, 95% CI: 5.65--21.75; versus ≥60 years; β, 1.03, 95% CI: -5.58 to 7.63; P interaction = 0.006); or with lower total homocysteine levels [<12.1 μmol/l (median); β, 12.70, 95% CI: 5.98--19.42; versus ≥12.1 μmol/l; β, 2.07, 95% CI: -5.63 to 9.78; P interaction = 0.030). None of the other variables, including sex, BMI, study centers, treatment group, SBP, triglycerides, total cholesterol, fasting blood glucose, folate, serum creatinine, current smoking and alcohol drinking, significantly modified the relation of hypertensive retinopathy with CIMT levels.

CONCLUSION

Hypertensive retinopathy (grade 2 and higher) was significantly associated with increased CIMT in hypertensive patients. The association was stronger in those of younger age or with lower total homocysteine levels.

Degree of Blood Pressure Control and Incident Diabetes Mellitus in Chinese Adults With Hypertension

Background

The association between blood pressure (BP) control and incident diabetes mellitus remains unknown. We aim to investigate the association between degree of time‐averaged on‐treatment systolic blood pressure (SBP) control and incident diabetes mellitus in hypertensive adults.

Methods and Results

A total of 14 978 adults with hypertension without diabetes mellitus at baseline were included from the CSPPT (China Stroke Primary Prevention Trial). Participants were randomized double‐masked to daily enalapril 10 mg and folic acid 0.8 mg or enalapril 10 mg alone. BP measurements were taken every 3 months after randomization. The primary outcome was incident diabetes mellitus, defined as physician‐diagnosed diabetes mellitus, or use of glucose‐lowering drugs during follow‐up, or fasting glucose ≥126 mg/dL at the exit visit. Over a median of 4.5 years, a significantly higher risk of incident diabetes mellitus was found in participants with time‐averaged on‐treatment SBP 130 to <140 mm Hg (10.3% versus 7.4%; odds ratio [OR], 1.37; 95% CI, 1.15‒1.64), compared with those with SBP 120 to <130 mm Hg. Moreover, the risk of incident diabetes mellitus increased by 24% (OR, 1.24; 95% CI, 1.00‒1.53) and the incidence of regression to normal fasting glucose (<100 mg/dL) decreased by 29% (OR, 0.71; 95% CI, 0.57‒0.89) in participants with intermediate BP control (SBP/diastolic blood pressure, 130 to <140 and/or 80 to <90 mm Hg), compared with those with a tight BP control of <130/<80 mm Hg. Similar results were found when the time‐averaged BP were calculated using the BP measurements during the first 6‐ or 24‐month treatment period, or in the analysis using propensity scores.

Conclusions

In this non‐diabetic, hypertensive population, SBP control in the range of 120 to <130 mm Hg, compared with the 130 to <140 mm Hg, was associated with a lower risk of incident diabetes mellitus.

Association of self-reported sleep duration and quality with BaPWV levels in hypertensive patients

The association between sleep conditions and arterial stiffness remains inconclusive. We aimed to investigate the relationship of sleep duration and quality with brachial-ankle pulse-wave velocity (baPWV) in hypertensive patients. A total of 14,485 hypertensive adults were included in this cross-sectional analysis. Information about sleep duration and quality was obtained via questionnaire. A baPWV level ≥1800 cm/s was defined as indicative of arterial stiffness. Compared with participants with a sleep duration <8 h per day, participants with a sleep duration ≥8 h per day had a significantly higher baPWV level (β = 13.7 cm/s; 95% CI: 3.9, 23.5) and a nonsignificantly higher prevalence of arterial stiffness (39.7% vs. 33.0%; OR, 1.08; 95% CI: 0.99-1.19). Similarly, compared with participants with good or medium sleep quality, participants with poor sleep quality had a significantly higher baPWV level (β = 16.3 cm/s; 95% CI: 0.1, 32.6) and a nonsignificantly greater prevalence of arterial stiffness (36.6% vs. 35.3%; OR, 1.13; 95% CI: 0.97-1.32). When sleep duration and quality were examined jointly, participants with a sleep duration ≥8 h and/or poor sleep quality had a significantly higher baPWV level (β = 14.4 cm/s; 95% CI: 5.3, 23.4) and a greater prevalence of arterial stiffness (38.8% vs. 32.7%; OR, 1.10; 95% CI: 1.01-1.20) than those with a sleep duration <8 h and good/medium sleep quality. In summary, among hypertensive patients, a longer sleep duration (≥8 h per day) and poor sleep quality were associated with higher baPWV levels and a higher prevalence of arterial stiffness.

The U-shaped association between achieved blood pressure and risk of cardiovascular events and mortality in elderly and younger patients

OBJECTIVE

The main objective is to assess the appropriate level of achieved SBP and DBP to prevent cardiovascular events.

METHODS

We used the National Sample Cohort from the National Health Insurance Service in Korea and analyzed data of 44 462 hypertensive patients aged 20--84 years. Achieved SBP and DBP were categorized according to average achieved SBP (<120, 120-129, 130-139, 140-149, and ≥150 mmHg) and DBP (<70, 70-79, 80-89, 90-99, and ≥100 mmHg). We examined the association between achieved BP and composite outcome including cardiovascular death, admission of stroke, myocardial infarction, or heart failure, and all-caused death in elderly aged more than 65 years and in younger patients.

RESULTS

After a median follow-up of 6.8 years, achieved SBP less than 120 mmHg and at least 150 mmHg in elderly and younger patients, respectively, were significantly associated with a higher risk of composite outcome than achieved SBP of 120-129 mmHg. Cox's proportional hazard analysis showed that the association between achieved SBP and risk of composite outcome and all-cause death had U-shaped relationships and identified a nadir of SBP of 135.6 and 128.9 mmHg, respectively, for composite outcome and 135.1 and 131.4 mmHg, respectively, for all-cause death in elderly and younger patients.

CONCLUSION

Compared with SBP of 120-129 mmHg, not only low achieved SBP of less than 120 mmHg but also high BP are associated with risk of adverse cardiovascular event and all-cause death in both elderly and younger patients with a distinct U-shaped relationship.

Baseline Serum Bilirubin and Risk of First Stroke in Hypertensive Patients

Background

Data on the association between serum bilirubin and the risk of stroke are limited and inconclusive. We aimed to evaluate the association between serum bilirubin and the risk of first stroke and to examine any possible effect modifiers in hypertensive patients.

Methods and Results

Our study was a post hoc analysis of the CSPPT (China Stroke Primary Prevention Trial). A total of 19 906 hypertensive patients were included in the final analysis. Cox proportional hazards models were used to estimate the hazard ratios (HRs) and 95% CIs for the risk of first stroke associated with serum bilirubin levels. The median follow‐up period was 4.5 years. When serum total bilirubin was assessed as tertiles, the adjusted HR of first ischemic stroke for participants in tertile 3 (12.9–34.1 μmol/L) was 0.75 (95% CI, 0.59–0.96), compared with participants in tertile 1 (<9.3 μmol/L). When direct bilirubin was assessed as tertiles, a significantly lower risk of first ischemic stroke was also found in participants in tertile 3 (2.5–24.8 μmol/L) (adjusted HR, 0.77; 95% CI, 0.60–0.98), compared with those in tertile 1 (<1.6 μmol/L). However, there was no significant association between serum total bilirubin (tertile 3 versus 1: adjusted HR, 1.45; 95% CI, 0.89–2.35) or direct bilirubin (tertile 3 versus 1: adjusted HR, 1.27; 95% CI, 0.76–2.11) and first hemorrhagic stroke.

Conclusions

In this sample of Chinese hypertensive patients, there was a significant inverse association between serum total bilirubin or direct bilirubin and the risk of first ischemic stroke.

Relationship of visceral adiposity index with new-onset proteinuria in hypertensive patients

BACKGROUND & AIMS

Visceral adiposity index (VAI) is a sex-specific surrogate marker of adipose tissue distribution and function. Little is known about the longitudinal relationship between VAI and proteinuria. This study aimed to examine the prospective relationship of baseline VAI with new-onset of proteinuria in hypertensive patients without major cardiovascular diseases.

METHODS

A total of 10 699 hypertensive patients without proteinuria (negative urine dipstick reading) at baseline from the renal sub-study of the China Stroke Primary Prevention Trial (CSPPT) were included. Participants were randomly assigned to a double-blind daily treatment with 10 mg enalapril and 0.8 mg folic acid or 10 mg enalapril alone. Participants were followed every 3 months after randomization. The primary outcome was new-onset proteinuria, defined as a urine dipstick reading of ≥1+ at the exit visit. The secondary outcome was progression of proteinuria, defined as a urine dipstick reading of trace or ≥1+ at the exit visit.

RESULTS

During a median follow-up duration of 4.4 years, a total of 396 (3.7%) participants developed new-onset proteinuria, while 1236 (11.6%) participants met progression of proteinuria. When VAI was categorized into quartiles, compared with participants in quartile 1-3 (<2.99), a significantly higher risk of new-onset proteinuria (OR, 1.43; 95%CI: 1.07-1.91) and progression of proteinuria (OR, 1.23; 95%CI: 1.03-1.46) was found in those in quartile 4 (≥2.99). Moreover, the positive association was consistent in participants with or without general obesity, abdominal obesity, and dyslipidemia (all P-interactions > 0.05).

CONCLUSIONS

There was a positive association between VAI levels and the risk of new-onset proteinuria in hypertensive patients.

The implications of blood pressure targets from the 2018 European Society of Cardiology hypertension guidelines in Asian patients: a systematic review and meta-analysis

BACKGROUND

The evidence for optimal blood pressure (BP) targets in Asian patients with hypertension is insufficient and controversial. Western guidelines should be used with caution in clinical practice until there is supporting evidence.

OBJECTIVE

Systematically synthesize the evidence on the efficacy of achieving the strict 2018 European Society of Cardiology (ESC) guideline BP targets versus standard BP targets in Asian patients.

DATA SOURCES

We searched PubMed, Web of Science, Scopus, the Cochrane Central Register of controlled trials, and additional databases to retrieve relevant Asian studies.

STUDY SELECTION

Randomized controlled trials (RCTs) and observational studies that reported clinical endpoints, had a minimal follow-up period of one year and included Asian patients older than 18 years with essential hypertension.

DATA EXTRACTION

Two investigators independently conducted the study selection with any discrepancies resolved between team members.

DATA SYNTHESIS

We selected 15 studies for analysis (4 RCTs, 7 observational studies, and 4 post-hoc analyses). The evidence for the strict BP targets in elderly patients was insufficient. In middle-aged patients, the meta-analysis of observational studies revealed a significant reduction in major adverse cardiac events (MACCE) (hazard ratio (HR)=0.78; 95% confidence interval (CI: 0.74-0.81). For studies that reported results for patients of any age, the tight systolic BP-lowering therapy was associated with a decrease in MACCE (HR=0.80; 95% CI: 0.69-0.92), stroke (HR=0.82; 95% CI: 0.71-0.94), but not in cardiac events (HR=0.91; 95% CI: 0.72-1.14, P=.41), all-cause (HR=0.80; 95% CI: 0.57-1.13) and cardiovascular mortality (HR=0.73; 95% CI: 0.40-1.33, P=.30). Similar findings were obtained for the strict diastolic BP targets.

CONCLUSION

Our findings provide evidence for Asian patients that support the efficacy of the strict antihypertensive treatment with BP targets proposed by the 2018 ESC hypertension guidelines for the prevention of cardiovascular events. However, these data were obtained from only observational studies and the results were not confirmed by RCTs, probably due to insufficient power. Therefore, further high-quality RCTs are crucial.

LIMITATIONS

Use of aggregated data, the subgroup and meta-regression analyses are inconclusive, limited to English language, unable to estimate summary measures for some outcomes, publication bias difficult to assess, and unclear that results could be extrapolated.

REGISTRATION

The protocol registered in PROSPERO (CRD42018115570).

CONFLICT OF INTEREST

None.

Association between plasma retinol levels and the risk of all-cause mortality in general hypertensive patients: A nested case-control study

To evaluate the association between plasma retinol levels with all-cause mortality and investigate the possible effect modifiers in general hypertensive patients with no previous cardiovascular disease (CVD). This case-control study was nested in the China Stroke Primary Prevention Trial (CSPPT), a randomized, double-blind, controlled trial conducted in 32 communities in Anhui and Jiangsu provinces in China. The current study included 617 cases of all-cause mortality and 617 controls matched on age (≤1 year), sex, treatment group, and study site. All-cause mortality was the main outcome in this analysis, which included death due to any reason. The median follow-up duration was 4.5 years. Overall, there was a U-shaped relation of plasma retinol with all-cause mortality. In the threshold effect analysis, the risk of all-cause mortality significantly decreased with the increase in plasma retinol (per 10 μg/dL increments: OR, 0.73; 95% CI: 0.61-0.87) in participants with plasma retinol <58.3 μg/dL and increased with the increase in plasma retinol (per 10 μg/dL increments: OR, 1.08; 95% CI: 1.01-1.16) in those with plasma retinol ≥58.3 μg/L. In participants with plasma retinol <58.3 μg/dL, a stronger inverse association was observed in those with higher time-averaged SBP (≥140 vs <140 mm Hg; P-interaction = .034), or higher vitamin E levels (≥11.5 [quartile 4]; vs <11.5 μg/mL; P-interaction = .013). The present study demonstrated that there was a U-shaped relationship of plasma retinol levels with the risk of all-cause mortality in general hypertensive patients, with a turning point around 58.3 μg/dL.

Carotid Intima-Media Thickness and the Risk of First Stroke in Patients With Hypertension

Background and Purpose—

This study aimed to investigate the association between mean carotid intima-media thickness (cIMT) and the risk of first stroke and examine any possible effect modifiers in patients with hypertension.

Methods—

A total of 11 547 hypertensive participants without history of stroke from the CSPPT (China Stroke Primary Prevention Trial) were included in this analysis. The primary outcome was first stroke.

Results—

Over a median follow-up of 4.4 years, 726 first strokes were identified, of which 631 were ischemic, and 90 were hemorrhagic. A per SD increase in mean cIMT was positively associated with the risk of first stroke (hazard ratio [HR], 1.11 [95% CI, 1.03–1.20]), and first ischemic stroke (HR, 1.10 [95% CI, 1.01–1.20]). Moreover, when cIMT was categorized in quartiles, the higher risks of first stroke (HR, 1.31 [95% CI, 1.06–1.61]) and first hemorrhagic stroke (HR, 2.25 [95% CI, 1.11–4.58]) were found in participants in quartile 2 to 4 (≥0.66 mm), compared with those in quartile 1 (<0.66 mm). More importantly, the cIMT-first stroke association was significantly stronger in participants with higher mean arterial pressure (≥109.3 [quintile 5] versus <109.3 mm Hg, P -interaction=0.024) or diastolic blood pressure levels (≥90.7 [quintile 5] versus <90.7 mm Hg, P -interaction=0.009).

Conclusions—

There was a significant positive association between baseline cIMT and the risk of first stroke in patients with hypertension. This association was even stronger among those with higher mean arterial pressure or diastolic blood pressure levels.

Interaction of serum vitamin B12 and folate with MTHFR genotypes on risk of ischemic stroke

OBJECTIVE

We evaluated the interaction of serum folate and vitamin B₁₂ with methylenetetrahydrofolate reductase (MTHFR) C677T genotypes on the risk of first ischemic stroke and on the efficacy of folic acid treatment in prevention of first ischemic stroke.

METHODS

A total of 20,702 hypertensive adults were randomized to a double-blind treatment of daily enalapril 10 mg and folic acid 0.8 mg or enalapril 10 mg alone. Participants were followed up every 3 months.

RESULTS

Median values of folate and B₁₂ concentrations at baseline were 8.1 ng/mL and 280.2 pmol/L, respectively. Over a median of 4.5 years, among those not receiving folic acid, participants with baseline serum B₁₂ or serum folate above the median had a significantly lower risk of first ischemic stroke (hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.57-0.96), especially in those with MTHFR 677 CC genotype (wild-type) (HR, 0.49; 95% CI, 0.31-0.78). Folic acid treatment significantly reduced the risk of first ischemic stroke in participants with both folate and B₁₂ below the median (2.3% in enalapril-folic acid group vs 3.6% in enalapril-only group; HR, 0.62; 95% CI, 0.46-0.86), particularly in MTHFR 677 CC carriers (1.6% vs 4.9%; HR, 0.24; 95% CI, 0.11-0.55). However, TT homozygotes responded better with both folate and B₁₂ levels above the median (HR, 0.28; 95% CI, 0.10-0.75).

CONCLUSIONS

The risk of first ischemic stroke was significantly higher in hypertensive patients with low levels of both folate and B₁₂. Effect of folic acid treatment was greatest in patients with low folate and B₁₂ with the CC genotype, and with high folate and B₁₂ with the TT genotype.

The Association Between Sleep Duration, Asthma-Related Episodes/Attacks and Emergency Department Visits

BACKGROUND

Inadequate sleep duration potentially increases the risk of allergic asthma; yet, the effect of different sleep duration on asthma-related episodes/attacks and emergency department (ED) visits has remained unclear. The purpose of this study is to evaluate the association between sleep duration, asthma-related episodes/attacks and ED visits.

METHODS

This study included 1526 asthma participants from the Behavioral Risk Factor Surveillance System Questionnaire during 2013-2017. Self-reported sleep duration was classified into three groups: ≤6 h (short), 7 h to 8 h (optimal) and ≥9 h (long). Generalized additive model with binomial or Poisson regression was used to complete all statistical analyses.

RESULTS

During a 12-month period, 857 participants reported acute episodes/attacks of asthma, and 279 participants reported asthma-related ED visits. Asthmatics with ED visits harbored significantly lower mean sleep duration (6.50 h vs 7.01 h, adjusted OR=0.93, 95% CI: 0.88-0.98) than those without episodes/attacks. After adjusting the potential confounding factors, the participants with long sleep duration were associated with lower risk of asthma-related episodes/attacks (adjusted OR=0.59, 95% CI: 0.41-0.86) than those with short sleep duration. The prevalence (adjusted OR=0.67, 95% CI: 0.47-0.94) and frequency (adjusted OR=0.83, 95% CI: 0.69-0.9996) of asthma-related ED visits among short sleepers were significantly higher than that among optimal sleepers. The differences of asthma-related episodes/attacks and ED visits between long and optimal sleepers were statistically insignificant.

CONCLUSION

Our study demonstrated that asthmatics with short sleep duration were associated with highest prevalence of asthma-related episodes/attacks and ED visits among the three sleep duration groups.

Baseline Plasma Zinc and Risk of First Stroke in Hypertensive Patients

Background and Purpose—

We aimed to examine the relation of baseline plasma zinc with the risk of first stroke and investigate any possible effect modifiers in hypertensive patients.

Methods—

The study population was drawn from the CSPPT (China Stroke Primary Prevention Trial), using a nested case-control design, including 599 first stroke cases and 599 matched controls.

Results—

Compared with participants with baseline plasma zinc <106.9 μg/dL (median), a significantly lower risk of first hemorrhagic stroke was found in those with plasma zinc ≥106.9 μg/dL (multivariate-adjusted odds ratio, 0.45; 95% CI, 0.21–0.94). Furthermore, the inverse plasma zinc-first hemorrhagic stroke association was significantly stronger in participants with body mass index ≥25.0 kg/m 2 or plasma copper <100.1 μg/dL at baseline ( P interaction <0.05 for both variables). However, there was no significant association between plasma zinc and first ischemic stroke (<103.3 versus ≥103.3 μg/dL [median]; multivariate-adjusted odds ratio, 1.16; 95% CI, 0.83–1.61).

Conclusions—

In this sample of hypertensive patients, we found a significant, inverse association between plasma zinc and first hemorrhagic stroke.

Clinical Trial Registration—

URL: https://www.clinicaltrials.gov . Unique identifier: NCT00794885.

Plasma copper and the risk of first stroke in hypertensive patients: a nested case-control study

BACKGROUND

Previous studies indicated that trace elements may play an important role in cardiovascular diseases. However, data concerning the association between blood copper and the risk of stroke are limited.

OBJECTIVE

The aim of this study was to evaluate the association between plasma copper and the risk of first stroke, and examine any possible effect modifiers in hypertensive patients.

METHODS

We conducted a nested case-control study, using data from the China Stroke Primary Prevention Trial. Hypertension is defined as systolic blood pressure ≥ 140 mm Hg or diastolic blood pressure ≥ 90 mm Hg, or taking antihypertensive medication. A total of 618 first stroke cases and 618 controls matched for age, sex, treatment group, and study site were included in this study. The crude and adjusted risks of first stroke were estimated by ORs and 95% CIs using conditional logistic regression, without or with adjusting for pertinent covariates, respectively.

RESULTS

There were significant positive associations of plasma copper with risk of first stroke (per SD increment-OR: 1.20; 95% CI: 1.03, 1.39) and first ischemic stroke (OR: 1.26; 95% CI: 1.07, 1.50). When plasma copper was categorized in quartiles, significantly higher risks of first stroke (OR: 1.72; 95% CI: 1.12, 2.65) and first ischemic stroke (OR: 1.91; 95% CI: 1.18, 3.11) were found in participants in quartile 4 (≥ 117.0 μg/dL) than in those in quartile 1 (< 91.2 μg/dL). Furthermore, the plasma copper-first stroke association was significantly stronger in participants with higher BMI (< 25.0 compared with ≥ 25.0 kg/m2, P-interaction = 0.024). However, there was no significant association between plasma copper and first hemorrhagic stroke.

CONCLUSIONS

In Chinese hypertensive patients, there was a significant positive association between baseline plasma copper and the risk of first stroke, especially among those with higher BMI.This trial was registered at clinicaltrials.gov as NCT00794885.

[New Targets in Blood Pressure Control: Arguments Pro and Contra]

The review contains results of analysis of clinical studies on the problem of defining the target level of the blood pressure (BP). The rationale for selection the target systolic BP level below120 mmHg was obtained in the SPRINT study comparing the target levels &lt;120 mmHg and &lt;140 mmHg. A considerably lower number of cardiovascular complications and deaths was seen in the group of a stricter BP control. Nevertheless, this study had some limitations related to certain patient populations, and methods of BP measurement. More ambitious target of BP lowering was associated with elevated risk of iatrogenic hypotension and fainting. Moreover, the ACCORD study, exploring the same target levels failed to demonstrate similar risk reduction. Taking into account various literature data, the authors find it reasonable to use personalized approach to determining BP targets, and utilize assessment of central aortic pressure and state of vessels for more accurate risk stratification and selection of treatment.

U-shaped association between serum albumin and development of chronic kidney disease in general hypertensive patients

BACKGROUND & AIMS

We aimed to examine the association between serum albumin (SAlb) and the development of chronic kidney disease (CKD), and examine any possible effect modifiers in general hypertensive patients with normal renal function and with no previous cardiovascular diseases (CVD).

METHODS

This is a post-hoc analysis (performed at May, 2018) of 12,621 hypertensive adults with estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m² and SAlb ≥35.0 g/L from the renal sub-study of the China Stroke Primary Prevention Trial (CSPPT), conducted from May 2008 to August 2013. The primary outcome was development of CKD, defined as a decrease in eGFR of ≥30% and to a level of <60 mL/min/1.73 m²; or end stage renal disease.

RESULTS

The median follow-up duration was 4.4 years. Overall, the association between SAlb levels and risk of the primary outcome followed a U-shape. The risk of CKD development significantly decreased with the increment of SAlb (per g/L: OR = 0.92; 95% CI: 0.88-0.96) in participants with SAlb <51.4 g/L, and increased with the increment of SAlb (per g/L: OR = 1.06; 95%CI: 1.01-1.11) in participants with SAlb ≥51.4 g/L. Moreover, in participants with SAlb <51.4 g/L, the association between SAlb and CKD development remained significant in participants without proteinuria (per g/L: OR = 0.93; 95% CI: 0.88-0.99). The association between SAlb and CKD development was not significantly modified by age, sex, folic acid treatment, proteinuria, systolic blood pressure (SBP) at baseline and time-averaged SBP during the treatment period (all P-interactions>0.05).

CONCLUSIONS

There was a U-shaped association between SAlb levels and risk of CKD development among general hypertensive patients with normal renal function and without CVD, with a turning point at about 51.4 g/L.

Plasma retinol and the risk of first stroke in hypertensive adults: a nested case-control study

Background

Identification of novel risk factors is needed to further lower stroke risk. Data concerning the association between plasma retinol concentrations and the risk of stroke are limited.

Objectives

We aimed to evaluate the effect of plasma retinol on the risk of first stroke and to examine any possible effect modifiers in hypertensive patients.

Methods

The study sample population was drawn from the China Stroke Primary Prevention Trial (CSPPT), using a nested case-control design, including 620 cases with first stroke and 620 matched controls. In the CSPPT, a total of 20,702 hypertensive patients were randomly assigned to a double-blind, daily treatment with either 10 mg enalapril and 0.8 mg folic acid or 10 mg enalapril alone. The median treatment duration was 4.5 y.

Results

There was a significant inverse association between plasma retinol and the risk of first stroke (per 10-μg/dL increment; OR: 0.92; 95% CI: 0.86, 0.97) and first ischemic stroke (OR: 0.92; 95% CI: 0.86, 0.98). When retinol was assessed as quartiles, significantly lower risks of first stroke (OR: 0.64; 95% CI: 0.46, 0.88) and first ischemic stroke (OR: 0.67; 95% CI: 0.46, 0.96) were found in participants in quartiles 2-4 compared with those in quartile 1. Furthermore, a stronger inverse association between plasma retinol and first stroke was observed in participants with baseline total homocysteine (<10 compared with ≥10 μmol/L; P-interaction = 0.049). However, plasma retinol had no significant effect on first hemorrhagic stroke (per 10-μg/dL increment; OR: 0.98; 95% CI: 0.79, 1.18).

Conclusions

Our data showed a significant inverse association between plasma retinol and the risk of first stroke among Chinese hypertensive adults. This study was registered at clinicaltrials.gov as NCT00794885.

Controversies in the 2017 ACC/AHA Hypertension Guidelines: Who Can Be Eligible for Treatments Under the New Guidelines? - An Asian Perspective

Until the 2017 ACC/AHA Hypertension Guidelines were released, the target blood pressure (BP) for adults with hypertension (HTN) was 140/90 mmHg in most of the guidelines. The new 2018 ESC/ESH, Canadian, Korean, Japan, and Latin American hypertension guidelines have maintained the <140/90 mmHg for the primary target in the general population and encourage reduction to <130/80 if higher risk. This is more in keeping with the 2018 American Diabetes Association guidelines. However, the 2017 ACC/AHA guidelines classify HTN as BP ≥130/80 mmHg and generally recommend target BP levels below 130/80 mmHg for hypertensive patients independently of comorbid disease or age. Although the new guidelines mean that more people (nearly 50% of adults) will be diagnosed with HTN, the cornerstone of therapy is still lifestyle management unless BP cannot be lowered to this level; thus, more people will require BP-lowering medications. To date, there have been many controversies about the definition of HTN and the target BP. Targeting an intensive systolic BP goal can increase the adverse effects of multiple medications and the cardiovascular disease risk by excessively lowering diastolic BP, especially in patients with high risk, including those with diabetes, chronic kidney disease, heart failure, and coronary artery disease, and the elderly. In this review, we discuss these issues, particularly regarding the optimal target BP.

Blood Pressure Management for Stroke Prevention and in Acute Stroke

Elevated blood pressure (BP) is the leading modifiable risk factor for stroke and the benefit of BP lowering therapy on the stroke risk reduction is well established. The optimal BP target for preventing stroke and other vascular events have been controversial, but the evidences from epidemiological studies and randomized controlled trials (RCTs) support intensive BP lowering for greater vascular protection, particularly for stroke prevention. For secondary stroke prevention, the evidence of intensive BP lowering benefit is limited since only a single RCT for patients with lacunar infarctions was conducted and most data were driven by exploratory analyses. In acute intracerebral hemorrhage, immediate BP lowering targeting systolic BP<140 mm Hg is recommended by guidelines based on the results from RCTs. In contrast, in acute ischemic stroke, early BP lowering is not usually recommended because of no benefit on functional outcome and future vascular events and potential harm of stroke progression. This review aims to summarize the updated evidence for optimal BP management for primary and secondary stroke prevention and in patients with acute stroke.