Survey of blood pressure control status in patients with ischemic stroke or transient ischemic attack in China

Blood pressure control and antihypertensive medication use after discharge and prognosis of ischemic stroke

OBJECTIVE

To investigate the effect of consistently blood pressure (BP) control status after discharge on adverse clinical outcomes among ischemic stroke (IS) patients.

METHODS

Three thousand, four hundred and six acute IS patients were included and followed up at 3 months, 12 months, and 24 months after stroke. Study outcomes were defined as death, vascular events and composite of death or vascular events. Cox proportional hazard models were used to estimate hazard ratios (HR) and 95% confident interval (CI) of death and the composite outcome of death or vascular events associated with BP control and antihypertensive medication use.

RESULTS

The multivariable adjusted HRs were 0.22 [95% confidence interval (CI): 0.09-0.57] for death and 0.60 (95% CI: 0.39-0.97) for the composite outcome of death or vascular events among participants with consistently controlled BP compared with those with consistently uncontrolled BP. The participants with both consistently controlled BP and regular use of antihypertensive medication had the lowest risks of death [hazard ratio (HR): 0.18, 95% CI: 0.04-0.75] and composite outcome of death or vascular events (HR: 0.54, 95% CI: 0.29-0.98) in comparison with those with both uncontrolled BP and irregular use of antihypertensive medication.

DISCUSSION

Continuous BP control and regular use of antihypertensive medications after discharge can decrease the risks of death and composite outcome of death or vascular events among IS patients, suggesting the importance of continuous BP control and regular use of antihypertensive medications after discharge for improving prognosis of IS.

Prevalence, treatment, and attributed mortality of elevated blood pressure among a nationwide population-based cohort of stroke survivors in China

Background

Elevated blood pressure (BP) is associated with substantial morbidity and mortality in stroke survivors. China has the highest prevalence of stroke survivors and accounts for one-third of stroke-related deaths worldwide. We aimed to describe the prevalence and treatment of elevated BP across age, sex, and region, and assess the mortality attributable to elevated BP among stroke survivors in China.

Materials and methods

Based on 3,820,651 participants aged 35–75 years from all 31 provinces in mainland China recruited from September 2014 to September 2020, we assessed the prevalence and treatment of elevated BP (systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg) among those with self-reported stroke and stratified by age group, sex, and geographic region. We estimated the age- and sex-specific population attributable fractions of death from elevated BP.

Results

Among 91,406 stroke survivors, the mean (SD) age was 62 (8) years, and 49.0% were male. The median interquartile range (IQR) stroke duration was 4 (2, 7) years. The prevalence of elevated BP was 61.3% overall, and increased with age (from 47.5% aged 35–44 years to 64.6% aged 65–75 years). The increment of prevalence was larger in female patients than male patients. Elevated BP was more prevalent in northeast (66.8%) and less in south (54.3%) China. Treatment rate among patients with elevated BP was 38.1%, and rates were low across all age groups, sexes, and regions. Elevated BP accounted for 33 and 21% of cardiovascular and all-cause mortality among stroke survivors, respectively. The proportion exceeded 50% for cardiovascular mortality among patients aged 35–54 years.

Conclusion

In this nationwide cohort of stroke survivors from China, elevated BP and its non-treatment were highly prevalent across all age groups, sexes, and regions. Elevated BP accounted for nearly one-third cardiovascular mortality in stroke survivors, and particularly higher in young and middle-aged patients. National strategies targeting elevated BP are warranted to address the high stroke burden in China.

Risk factor control after ischemic stroke or transient ischemic attack

OBJECTIVE

We aimed to estimate the status of risk factor control after ischemic stroke or transient ischemic attack (IS/TIA), and the influence on recurrent stroke in rural communities of northeastern China.

METHODS

This population-based, prospective cohort study enrolled adults aged ≥35 years residing in rural northeastern China. We conducted cardiovascular health examinations in 2012-2015 and followed up in 2018 to record any cardiovascular event. Control of risk factors after IS/TIA was determined through a baseline survey. The Cox proportional hazard model was used to evaluate the relationship between uncontrolled risk factors and stroke recurrence.

RESULTS

Of the 10,700 participants, 575 were diagnosed with IS/TIA and were included in the analysis. At baseline, the rates of control of risk factors were as follows: fasting plasma glucose (FPG), 81.6%; not currently smoking, 65.7%; and achieving physical activity targets, 61%. Blood pressure (BP), low-density lipoprotein cholesterol (LDL-C), and body mass index (BMI) were poorly controlled (28.3%, 26.3%, and 37.4%, respectively). The rate of stroke recurrence was 12% during a median follow-up of 4.43 years. After adjusting for age, sex, ethnicity, family history of stroke, and current drinking, uncontrolled BP and not achieving physical exercise targets were associated with an increased risk of recurrence (hazard ratios: 2.081, 1.685, respectively; p < .05). Uncontrolled FPG, BMI, or LDL-C and current smoking did not significantly influence recurrent risk (p > .05).

CONCLUSIONS

Control of risk factors after IS/TIA needs to be improved in rural communities of northeastern China to prevent recurrence and thus alleviate the public health and economic burden of stroke.

Hypertension and TIA

Transient ischemic attack is a medical emergency because early stroke risk after transient ischemic attack is high. Hypertension is the most important modifiable risk factor for stroke and transient ischemic attack. The aims of this review are to provide a summary of the current knowledge concerning the relationship between blood pressure and transient ischemic attack, as well as outline issues regarding diurnal variation and the potential of chronotherapy (timing medications to accord with diurnal patterns of blood pressure). There is a strong relationship between hypertension and the incidence of transient ischemic attack and the subsequent short-term risk for stroke. Ambulatory blood pressure monitoring is a reliable diagnostic and monitoring tool for hypertension and provides additional information about diurnal variation in blood pressure. Different diurnal blood pressure patterns may confer variable stroke risk. Patients with stroke commonly have abnormal diurnal blood pressure patterns and this may relate, in part, to autonomic nervous system dysfunction. However, blood pressure patterns have not been systematically studied in patients with transient ischemic attack. Blood pressure remains poorly controlled in a large proportion of patients after transient ischemic attack and under-treatment and poor adherence are important factors. Chronotherapy for blood pressure may result in more effective blood pressure control. More research is needed in this area. Hypertension is strongly associated with transient ischemic attack. Diurnal blood pressure patterns may influence subsequent stroke risk after transient ischemic attack and more evidence is needed to inform clinical practice to improve blood pressure management for transient ischemic attack patients.

Stroke in China

1. Following rapid economic development in China, the epidemiological characteristics, management and prevention strategies for stroke are changing. In the present article, we review recent epidemiological data, as well as studies into the management and prevention of stroke in China. 2. The main findings of the studies reviewed suggest that stroke mortality in China has been reduced significantly. The percentage of haemorrhagic strokes in China is significantly higher than that reported in Western countries. The incidence and subtype of stroke varied widely in different regions in China. Some of the modifiable risk factors for stroke are on the increase in China, including hypertension. 3. Management of stroke is slowly being developed and standardized, as evidenced by the establishment of stroke units and improvements in emergency care. Studies on primary and secondary stroke prevention remain insufficient. Well-designed epidemiological surveys and clinical trials for stroke prevention and management are urgently needed in China.