Blood Pressure and Vascular Cognitive Impairment

Associations of Epigenetic Age Estimators With Cognitive Function Trajectories in the Women's Health Initiative Memory Study

BACKGROUND AND OBJECTIVES

Epigenetic age estimators indicating faster/slower biological aging vs chronological age independently associate with several age-related outcomes; however, longitudinal associations with cognitive function are understudied. We examined associations of epigenetic age estimators with cognitive function measured annually.

METHODS

This longitudinal study consisted of older women enrolled in the Women's Health Initiative Memory Study with DNA methylation (DNAm) collected at baseline (1995-1998) from 3 ancillary studies and were followed up to 13 years. Global cognitive function was measured annually by Modified Mini-Mental State Examination (3MS; baseline-2007) and by modified Telephone Interview for Cognitive Status (TICS-m, 2008-2021). We calculated 5 epigenetic age estimators: extrinsic AgeAccel, intrinsic AgeAccel, AgeAccelPheno, AgeAccelGrim2, Dunedin Pace of Aging Calculated From the Epigenome (DunedinPACE), and AgeAccelGrim2 components (DNA-based plasma protein surrogates). We estimated longitudinal epigenetic age estimator-cognitive function associations using linear mixed-effects models containing age, education, race or ethnicity, and subsequently alcohol, smoking, body mass index, and comorbidities. We examined effect modification by APOE ε4 carriage.

RESULTS

A total of 795 participants were enrolled. The mean baseline age was 70.8 ± 4 years (10.7% Black, 3.9% Hispanic or Latina, 85.4% White), A 1-SD (0.12) increment in DunedinPACE associated with faster annual declines in TICS-m scores in minimally adjusted (β = -0.118, 95% CI -0.202 to -0.034; p = 0.0006) and fully adjusted (β = -0.123, 95% CI -0.211 to -0.036; p = 0.006) models. AgeAccelPheno associated with faster annual declines in TICS-m with minimal adjustment (β = -0.091, 95% CI -0.176 to -0.006; p = 0.035) but not with full adjustment. No other epigenetic age estimators associated with changes in 3MS or TICS-m. Higher values of DNAm-based surrogates of growth differentiation factor 15, beta-2 microglobulin, Cystatin C, tissue inhibitor metalloproteinase 1, and adrenomedullin associated with faster annual declines in 3MS and TICS-m. Higher DNAm log A1c associated with faster annual declines in TICS-m only. DunedinPACE associated with faster annual declines in 3MS among APOE ε4 carriers but not among noncarriers (p-interaction = 0.020).

DISCUSSION

Higher DunedinPACE associated with faster declines in TICS-m and 3MS scores among APOE ε4 carriers. DunedinPACE may help identify older women at risk of future cognitive decline. Limitations include the ancillary studies that collected epigenetic data not designed to study epigenetics and cognitive function. We examined epigenetic age estimators with global cognitive function and not specific cognitive domains. Findings may not generalize to men and more diverse populations.

The Effect of Acupuncture on Brain Iron Deposition and Body Iron Metabolism in Vascular Cognitive Impairment: Protocol for a Randomized Controlled Trial

BACKGROUND

Vascular cognitive impairment (VCI) persistently impairs cognition and the ability to perform activities of daily living, seriously compromising patients' quality of life. Previous studies have reported that disorders of serum iron metabolism and iron deposition in the brain can lead to inflammation, abnormal protein aggregation and degeneration, and massive neuronal apoptosis in the central nervous system, which in turn leads to a progressive decline in cognitive processes. Our previous clinical studies have found acupuncture to be a safe and effective intervention for treating VCI, but the specific mechanisms require further exploration.

OBJECTIVE

The objective of the trial is to evaluate the clinical efficacy of Tongdu Xingshen acupuncture and to investigate whether it can improve VCI by regulating brain iron deposition and body iron metabolism.

METHODS

In total, 42 patients with VCI and 21 healthy individuals will participate in this clinical trial. The 42 patients with VCI will be randomized into acupuncture and control groups, while the 21 healthy individuals will be in the healthy control group. Both the control and acupuncture groups will receive conventional medical treatment and cognitive rehabilitation training. In addition, the acupuncture group will receive electroacupuncture treatment with Tongdu Xingshen for 30 minutes each time, 6 times a week for 4 weeks. Meanwhile, the healthy control group will not receive any intervention. All 3 groups will undergo baseline assessments of brain iron deposition, serum iron metabolism, and neuropsychological tests after enrollment. The acupuncture and control groups will be evaluated again at the end of 4 weeks of treatment, as described earlier. By comparing neuropsychological test scores between groups, we will examine the efficacy of Tongdu Xingshen acupuncture in treating VCI. Additionally, we will test the correlations between neuropsychological test scores, brain iron deposition, and body iron metabolism indexes to explore the possible mechanisms of Tongdu Xingshen acupuncture in treating VCI.

RESULTS

Participants are currently being recruited. The first participant was enrolled in June 2023, which marked the official start of the experiment. As of the submission of the paper, there were 23 participants. The recruitment process is expected to continue until June 2025, at which point the processing and analysis of data will begin. As of May 15, 2024, up to 30 people have been enrolled in this clinical trial.

CONCLUSIONS

This study will provide data on the effects of Tongdu Xingshen acupuncture on cerebral iron deposition as well as somatic iron metabolism in patients with VCI. These results will help to prove whether Tongdu Xingshen acupuncture can improve VCI by regulating brain iron deposition and body iron metabolism, which will provide the clinical and theoretical basis for the wide application of acupuncture therapy in VCI rehabilitation.

TRIAL REGISTRATION

China Clinical Registration Agency ChiCTR2300072188; https://tinyurl.com/5fcydtkv.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/56484.

Hypertension: Causes and Consequences of Circadian Rhythms in Blood Pressure

Hypertension is extremely common, affecting approximately 1 in every 2 adults globally. Chronic hypertension is the leading modifiable risk factor for cardiovascular disease and premature mortality worldwide. Despite considerable efforts to define mechanisms that underlie hypertension, a potentially major component of the disease, the role of circadian biology has been relatively overlooked in both preclinical models and humans. Although the presence of daily and circadian patterns has been observed from the level of the genome to the whole organism, the functional and structural impact of biological rhythms, including mechanisms such as circadian misalignment, remains relatively poorly defined. Here, we review the impact of daily rhythms and circadian systems in regulating blood pressure and the onset, progression, and consequences of hypertension. There is an emphasis on the impact of circadian biology in relation to vascular disease and end-organ effects that, individually or in combination, contribute to complex phenotypes such as cognitive decline and the loss of cardiac and brain health. Despite effective treatment options for some individuals, control of blood pressure remains inadequate in a substantial portion of the hypertensive population. Greater insight into circadian biology may form a foundation for novel and more widely effective molecular therapies or interventions to help in the prevention, treatment, and management of hypertension and its related pathophysiology.

Considerations for Use of Blood-Based Biomarkers in Epidemiologic Dementia Research

Dementia represents a growing public health burden with large social, racial, and ethnic disparities. The etiology of dementia is poorly understood, and the lack of robust biomarkers in diverse, population-representative samples is a barrier to moving dementia research forward. Existing biomarkers and other measures of pathology-derived from neuropathology, neuroimaging, and cerebrospinal fluid samples-are commonly collected from predominantly White and highly educated samples drawn from academic medical centers in urban settings. Blood-based biomarkers are noninvasive and less expensive, offering promise to expand our understanding of the pathophysiology of dementia, including in participants from historically excluded groups. Although largely not yet approved by the Food and Drug Administration or used in clinical settings, blood-based biomarkers are increasingly included in epidemiologic studies on dementia. Blood-based biomarkers in epidemiologic research may allow the field to more accurately understand the multifactorial etiology and sequence of events that characterize dementia-related pathophysiological changes. As blood-based dementia biomarkers continue to be developed and incorporated into research and practice, we outline considerations for using them in dementia epidemiology, and illustrate key concepts with Alzheimer's Disease Neuroimaging Initiative (2003-present) data. We focus on measurement, including both validity and reliability, and on the use of dementia blood-based biomarkers to promote equity in dementia research and cognitive aging. This article is part of a Special Collection on Mental Health.

Time in target range of systolic blood pressure and cognitive outcomes in patients with hypertension

BACKGROUND

Blood pressure (BP) is a dynamic measure that fluctuates over time. However, conventional BP control indicators may not adequately reflect the variability of BP during a period of time.

METHODS

We performed a secondary analysis of the Systolic Blood Pressure Intervention Trial (SPRINT), which compared systolic blood pressure (SBP) targets of <120 mmHg (intensive) and <140 mmHg (standard) among patients with hypertension and high cardiac risks. The target ranges were defined as 110 to 130 mmHg in intensive treatment arm and 120 to 140 mmHg in standard treatment arm, respectively. Time in target range (TTR) was calculated based on SBP measurements recorded during the first 3-month follow-up using linear interpolation method. The Fine-Gray competing risk regression models were used to evaluate the association between TTR and cognitive outcomes.

RESULTS

A total of 7965 patients with the mean (SD) age of 68.0 (9.2) years were included, and 35% were female. Patients with higher TTR were younger, more likely to be male and take <3 BP-lowering agents. Compared to the last quartile, the first quartile of TTR was significantly associated with a higher risk of probable dementia (HR: 1.74; 95% CI: 1.22-2.46; p = 0.002) and the composite of probable dementia or mild cognitive impairment (HR: 1.26; 95% CI: 1.03-1.55; p = 0.025). The risk of probable dementia and the composite outcome increased with per quartile decrease of TTR (HR: 1.18; 95% CI: 1.06-1.30; p = 0.002 and HR: 1.07; 95% CI: 1.00-1.14; p = 0.036). Sensitivity analyses showed similar results after adjusting mean SBP during the first 3-month follow-up.

CONCLUSIONS

In this secondary analysis of SPRINT data, TTR was independently associated with probable dementia among patients with hypertension, suggesting that TTR could be used as a practical metric of BP control to evaluate the risk of dementia in older adults.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Identifier: NCT01206062.

Cerebral Small Vessel Disease, Hypertension, and Vascular Contributions to Cognitive Impairment and Dementia

Hypertension-associated cerebral small vessel disease is a common finding in older people. Strongly associated with age and hypertension, small vessel disease is found at autopsy in over 50% of people aged ≥65 years, with a spectrum of clinical manifestations. It is the main cause of lacunar stroke and a major source of vascular contributions to cognitive impairment and dementia. The brain areas affected are subcortical and periventricular white matter and deep gray nuclei. Neuropathological sequelae are diffuse white matter lesions (seen as white matter hyperintensities on T2-weighted magnetic resonance imaging), small ischemic foci (lacunes or microinfarcts), and less commonly, subcortical microhemorrhages. The most common form of cerebral small vessel disease is concentric, fibrotic thickening of small penetrating arteries (up to 300 microns outer diameter) termed arteriolosclerosis. Less common forms are small artery atheroma and lipohyalinosis (the lesions described by C. Miller Fisher adjacent to lacunes). Other microvascular lesions that are not reviewed here include cerebral amyloid angiopathy and venous collagenosis. Here, we review the epidemiology, neuropathology, clinical management, genetics, preclinical models, and pathogenesis of hypertensive small vessel disease. Knowledge gaps include initiating factors, molecular pathogenesis, relationships between arterial pathology and tissue damage, possible reversibility, pharmacological targets, and molecular biomarkers. Progress is anticipated from multicell transcriptomic and proteomic profiling, novel experimental models and further target-finding and interventional clinical studies.

Meningeal interleukin-17-producing T cells mediate cognitive impairment in a mouse model of salt-sensitive hypertension

Hypertension (HTN), a disease afflicting over one billion individuals worldwide, is a leading cause of cognitive impairment, the mechanisms of which remain poorly understood. In the present study, in a mouse model of HTN, we find that the neurovascular and cognitive dysfunction depends on interleukin (IL)-17, a cytokine elevated in individuals with HTN. However, neither circulating IL-17 nor brain angiotensin signaling can account for the dysfunction. Rather, IL-17 produced by T cells in the dura mater is the mediator released in the cerebrospinal fluid and activating IL-17 receptors on border-associated macrophages (BAMs). Accordingly, depleting BAMs, deleting IL-17 receptor A in brain macrophages or suppressing meningeal T cells rescues cognitive function without attenuating blood pressure elevation, circulating IL-17 or brain angiotensin signaling. Our data unveil a critical role of meningeal T cells and macrophage IL-17 signaling in the neurovascular and cognitive dysfunction in a mouse model of HTN.

Forecasting the 20-Year Incidence of Dementia by Socioeconomic Status, Race/Ethnicity, and Region Based on Mid-Life Risk Factors in a U.S. Nationally Representative Sample

Background

Alzheimer's disease and related dementias (ADRD) incidence varies based on demographics, but mid-life risk factor contribution to this variability requires more research.

Objective

The purpose of this study is to forecast the 20-year incidence of dementia in the U.S. overall and stratified by race/ethnicity, socioeconomic status (SES), and U.S. geographic region given prior mid-life risk factor prevalence and to examine the extent to which risk factor differences 20 years ago may explain current SES, race/ethnicity, or regional disparities in dementia incidence.

Methods

We applied the Cardiovascular Risk Factors, Aging, and Incidence of Dementia (CAIDE) prediction model to the 2006 wave of the Health and Retirement Study (HRS) in participants aged 45 to 64 to estimate the 20-year risk of incident ADRD.

Results

The 20-year risk of dementia among middle-aged Americans was 3.3% (95% CI: 3.2%, 3.4%). Dementia incidence was forecast to be 1.51 (95% CI: 1.32, 1.71) and 1.27 (95% CI: 1.14, 1.44) times that in Hispanic and Non-Hispanic Black individuals respectively compared statistically to Non-Hispanic White individuals given mid-life risk factors. There was a progressive increase in dementia risk from the lowest versus highest SES quintile. For geographic region, dementia incidence was forecast to be 1.17 (95% CI: 1.06, 1.30) and 1.27 (95% CI: 1.14, 1.43) times that in Midwestern and Southern individuals respectively compared statistically to Western individuals.

Conclusions

Some disparities in dementia incidence could be explained by differences in mid-life risk factors and may point toward policy interventions designed to lessen the ADRD disease burden through early prevention.

Enlarged Perivascular Spaces in Relation to Cumulative Blood Pressure Exposure and Cognitive Impairment

BACKGROUND

Hypertension and enlarged perivascular spaces (EPVS) are thought to be associated with cognitive impairment. However, the correlations among hypertension, EPVS, and cognitive impairment have not been studied yet. We aimed to investigate the relationships between cumulative blood pressure (cBP) exposure with EPVS and cognitive impairment and whether EPVS may mediate the relationship between cBP and cognitive impairment.

METHODS

A total of 1507 subjects from the Kailuan prospective cohort study were enrolled. cBP was calculated from 2006 to 2022. The effects of cBP, EPVS scores, and cognitive impairment were evaluated using a logistic regression model. The relationships among cBP, EPVS score, and cognitive impairment were analyzed using a mediation model.

RESULTS

An increase in cBP was positively correlated with an increase in EPVS score. For every SD increase in cBP, the odds ratios (95% CI) of increased EPVS score of the centrum semiovale were 1.67 (1.43-1.95), 1.63 (1.4-1.9), and 1.35 (1.17-1.56), respectively; the odds ratios (95% CI) of increased EPVS score of the basal ganglia were 1.83 (1.56-2.15), 2.01 (1.7-2.36), and 1.31 (1.13-1.52), respectively; and the odds ratios (95% CI) of developing cognitive impairment were 1.28 (1.06-1.53), 1.13 (0.95-1.34), and 1.28 (1.07-1.5), respectively. Basal ganglia-EPVS score accounted for 10.46% to 18.32% of the mediating effects on the relationships of cBP/SD with cognitive impairment.

CONCLUSIONS

High cBP exposure was an independent risk factor for EPVS, and basal ganglia-EPVS score mediated the effects of cBP on cognitive impairment.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: ChiCTR-TNRC-11001489.

Early post-stroke cognitive impairment and in-hospital predicting factors among stroke survivors in Ethiopia

Background

In low-and middle-income countries, post-stroke cognitive impairment (PSCI) is the least investigated stroke complication that clinically is given little attention. Finding patients who are at high risk of having cognitive problems after a stroke could allow targeted follow-up and help with prognosis discussions, which would then contribute to improved treatment outcomes. The main aim of this study was to determine the incidence and predictors of PSCI among stroke survivors in Northwest Ethiopia.

Methods

The study was a multicenter prospective cohort study. The study participants were 403 stroke survivors who were alive on follow-up after 3 months of stroke onset at the neurology department of three hospitals in Northwest Ethiopia. To investigate the link between the outcome and the explanatory variables, analyses of bivariable and logistic multivariable regression were performed. A value of p of 0.05 or less was regarded as statistically significant, and data were presented as odds ratios and 95% confidence intervals.

Results

The mean age of the participants was 61.3 years (SD = 0.7), 56% were females, the mean time from symptom onset to hospital arrival was 46 h (SD = 3.32), and the mean National Institute of Health Stroke Scale (NIHSS) score at admission was 14.79 (SD = 0.25). PSCI was observed in 122 patients (30.3%) after 90 days of stroke onset, that is, 83 (20.6%) of female and 39 (9.7%) of male stroke survivors. The result of multivariable logistic regression analysis revealed PSCI was independently associated with age (adjusted OR = 1.04, 95% CI = 1.061-1.981), women (AOR = 1.390, 95% CI = 1.221-2.690), admission modified Rankin scale (mRS) (AOR = 1.629, 95% CI = 1.381-2.037), moderate Glasgow coma scale (GCS) score (AOR = 1.149, 95% CI = 1.402-3.281), and poor GCS score (AOR = 1.632, 95% CI = 1.610-4.361) and stage one (AOR = 1.428, 95% CI = 1.198-2.922) and stage two hypertension (AOR = 1.255, 95% CI = 1.107-2.609).

Conclusion

Nearly one-third of stroke survivors developed PSCI. Moreover, further research is needed with a larger sample size, showing a time trend and longer follow-up duration.

Systolic blood pressure at age 40 and cognitive function 25 years later: the Akershus Cardiac Examination (ACE) 1950 Study

OBJECTIVES

Hypertension in midlife is a risk factor for cognitive impairment. Still, the ideal midlife blood pressure (BP) remains unknown. We examined associations between different systolic blood pressure (SBP) levels at the age of 40-43 years and change in SBP over a 25-year period with cognitive function at age 62-65 years.

METHODS

We included 2424 individuals born in 1950 who had participated both in the Age 40 Program (1990-1993) and the Akershus Cardiac Examination (ACE) 1950 Study (2012-2015). The exposure was SBP at age 40-43 years and the outcome was cognitive function at age 62-65 years, assessed with Montreal Cognitive Assessment, Delayed recall trial from the Consortium to Establish a Registry for Alzheimer's Disease Word List Memory Task, and Trail Making Test part B (TMT B).

RESULTS

Participants were 40.1 ± 0.3 years old with mean SPB 128 ± 13 mmHg at the Age 40 Program, and 63.9 ± 0.6 years old with mean SPB 138 ± 18 at the ACE 1950 Study. Adjusted linear regressions showed no associations between SBP and subsequent cognitive function. In logistic regressions, individuals with SBP ≥140 mmHg, compared to individuals with SBP <120 mmHg (odds ratio 2.29, 95% confidence interval 1.28-4.10, P-value 0.005) had increased risk of an abnormal TMT B-score. Change in SBP during the 25-year follow-up was not associated with cognitive function.

CONCLUSIONS

SBP ≥140 mmHg at age 40-43 was associated with reduced capacity on TMT B, a domain specific cognitive test sensitive to vascular impairment. No other associations were found between SBP, or change in SBP, and cognitive function.

Hypertension, Neurovascular Dysfunction, and Cognitive Impairment

Hypertension affects a significant proportion of the adult and aging population and represents an important risk factor for vascular cognitive impairment and late-life dementia. Chronic high blood pressure continuously challenges the structural and functional integrity of the cerebral vasculature, leading to microvascular rarefaction and dysfunction, and neurovascular uncoupling that typically impairs cerebral blood supply. Hypertension disrupts blood-brain barrier integrity, promotes neuroinflammation, and may contribute to amyloid deposition and Alzheimer pathology. The mechanisms underlying these harmful effects are still a focus of investigation, but studies in animal models have provided significant molecular and cellular mechanistic insights. Remaining questions relate to whether adequate treatment of hypertension may prevent deterioration of cognitive function, the threshold for blood pressure treatment, and the most effective antihypertensive drugs. Recent advances in neurovascular biology, advanced brain imaging, and detection of subtle behavioral phenotypes have begun to provide insights into these critical issues. Importantly, a parallel analysis of these parameters in animal models and humans is feasible, making it possible to foster translational advancements. In this review, we provide a critical evaluation of the evidence available in experimental models and humans to examine the progress made and identify remaining gaps in knowledge.

Executive Function Poststroke: Concepts, Recovery, and Interventions

Executive function is frequently impaired among people who have sustained stroke. This review provides an overview of definitions, concepts, and measures. The review also summarizes current best evidence examining executive function impairment and recovery trajectories after stroke, correlates of change over time, and emerging intervention research. Finally, this review provides recommendations for research and clinical practices, as well as priorities for future executive function research.

Carotid disease, cognition, and aging: time to redefine asymptomatic disease?

There is an increasing appreciation of the vascular contributions in the development of age-related cognitive impairment and dementia^1,2. Identifying risk and maintaining cognitive health for successful aging is ever relevant in our aging population. Carotid disease, a well-established risk factor for stroke and often a harbinger of other vascular disease states, is also emerging as another vascular risk factor for age-related cognitive decline. When combined with vascular risk factors, the incidence of age-related carotid disease can be as high as 70%^3,4. Historically, carotid disease has been dichotomized into two large groups in trial design, outcome measurements, and treatment decisions: symptomatic and asymptomatic carotid artery stenosis. The dichotomous distinction between asymptomatic and symptomatic carotid stenosis based on existing definitions may be limiting the care we are able to provide for patients classified as "asymptomatic" from their carotid disease. Medically, we now know that these patients should be treated with the same intensive medical therapy as those with "symptomatic" carotid disease. Emerging data also shows that hypoperfusion from asymptomatic disease may lead to significant cognitive impairment in the aging population, and it is plausible that most "age-related" cognitive changes may be reflective of vascular impairment and neurovascular dysfunction. While over the past 30 years medical, surgical, and radiological advances have pushed the field of neurovascular disease to significantly reduce the number of ischemic strokes, we are far from any meaningful interventions to prevent vascular cognitive impairment. In addition to including cognitive outcome measures, future studies of carotid disease will also benefit from including advanced neuroimaging modalities not currently utilized in standard clinical imaging protocols, such as perfusion imaging and/or functional connectivity mapping, which may provide novel data to better assess for hypoxic-ischemic changes and neurovascular dysfunction across diffuse cognitive networks. While current recommendations advise against widespread population screening for asymptomatic carotid stenosis, emerging evidence linking carotid stenosis to cognitive impairment prompts us to re-consider our approach for older patients with vascular risk factors who are at risk for cognitive decline.

Night blood pressure variability, brain atrophy, and cognitive decline

Background

Although blood pressure variability (BPV) has emerged as a novel risk factor for Alzheimer's disease, few studies have examined the effects of night BPV on brain structure and function. This study investigated the association of night BPV with brain atrophy and cognitive function changes.

Methods

The analysis included 1,398 participants with valid ambulatory blood pressure (BP) monitoring at baseline and both baseline and 4-year follow-up brain magnetic resonance images who were recruited from the Korean Genome and Epidemiology Study. Participants underwent a comprehensive neuropsychological test battery. BPV was derived from ambulatory BP monitoring and calculated as a standard deviation (SD) of 24-h and daytime and nighttime BP.

Results

During the median follow-up of 4.3 years, increased SD of night systolic or diastolic BP was an indicator of total brain volume reduction, while daytime BPV or night average BP was not associated with total brain volume changes. High SD of night systolic BP was associated with reduced gray matter (GM) volume, independent of average night BP, and use of antihypertensive drugs. It also was associated with a reduction of temporal GM volume, mostly driven by atrophy in the left entorhinal cortex and the right fusiform gyrus. In cognitive performance, high variability of night systolic BP was associated with a decrease in visual delayed recall memory and verbal fluency for the category.

Conclusion

Increased night BPV, rather than night mean BP, was associated with reduced brain volume and cognitive decline. High night BPV could be an independent predictor for rapid brain aging in a middle-aged population.

More Than Just the Target: Blood Pressure, Stroke, and Vascular Cognitive Impairment

Despite effective treatments, hypertension remains a leading risk factor of any stroke, stroke recurrence, and vascular cognitive impairment. Hypertension is underdiagnosed and undertreated, both in the primary and secondary prevention setting. The current issue of Stroke includes a Focused Update series of 6 review articles covering differing aspects of hypertension and cerebrovascular disease. Traditionally, the goal of antihypertensive treatment has been risk reduction through reaching defined targets, a "one-size-fits-all" approach, both in the acute stroke and in secondary prevention. In this series, there is a shift toward a more individualized approach to blood pressure management in patients suffering from stroke or vascular cognitive impairment, taking several factors in addition to a defined target into account.