Hypertension and Stroke

STROKE AND MAJOR HEALTH BURDEN

Leading cause of death
and disability.
15 million people
worldwide suffer a
stroke/year and 1/3
individuals will die.
1/3 will be left
permanently disabled,
affecting quality of life.

The total incidence of stroke is expected to increase

considerably over the next two decades.
In other, less developed regions of the world, stroke is
reaching pandemic proportions as a result of rapid
urbanization and industrialization.

Wang et al, 2009

NEUROBIOL CASCADES OF STROKE

Vasc Isch Events Glut Toxic Excess Na and Ca Influx Ionic Pump
Fail Stim Active Subs Immun React Energy Prod Fail Mitoch/
Nuclear Injury Apoptosis ROS Necrosis Neuronal Cells Death.

HYPERTENSION AND STROKE PREVENTION

Systolic blood pressure

3 mmHg SBP
reduction

10 mmHg SBP
reduction

35% Stroke risk

reduction in
subjects aged
60 to 69 years

20% to 30%.
Stroke risk
reduction
A meta-analysis of
nine randomized
comparative trials

Two cohort study

overviews

Antihypertensive treatment that effectively reduces BP to

target levels may therefore be one of the most
important approaches for reducing the risk of stroke.

Grassi et al, 2007

HYPERTENSION AND STROKE PREVENTION

Wang et al, 2009

Terms and Conditions

Source: The Lancet Neurology 2009; 8:345-354 (DOI:10.1016/S1474-4422(09)70023-7)

OUTCOMES AFTER ISCHEMIC STROKE

___________________________________
Stroke recurrence
30 day
3 % - 10 %
1 year
5 % - 14 %
5 year
25 % - 40 %

Mortality
30 day
1 year
5 year

8 20 %
15 25 %
40 60 %

Functional Disability
24 53 % of stroke
survivor with complete or
partial dependences
Quality of life decrease in
27 %
Dementia or cognitive
decline 34 % at 52 week
post stroke
Sacco RL . Neuroloy 1997;49:S19-S44
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RISK FACTOR OF STROKE AND CAD

STROKE

CAD

HYPERTENSION
DISLIPIDEMIA

VASCULAR DISEASES

THE POPULATION-ATTRIBUTABLE RISK OF

COMMON RISK FACTORS

Tu J.V. Reducing the global burden of stroke: INTERSTROKE. Lancet.2010; 376(9735)

9
:74-75

THE DEADLY QUARTET

Diabetes
Diabetes

Obesity

Hypertension

Dyslipidemia

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 INDONESIA

RISKESDAS 2007
Stroke is a leading cause of death
In all age > 5 year
Age 45-54

15,4 %
15,9 %

Age 55-64

26,0 %

Prevalence of hypertension in age > 18 year

: 29,8 %
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BP Reductions as Small as 2 mmHg

reduce the Risk of CV Events by up to 10%

IHD mortality
7%

Mean SBP
2 mmHg

Stroke mortality
10%

Meta-analysis of 61 prospective, observational studies

1 million adults

12.7 million person-years

Prospective Studies Collaboration.

. Lancet 2002;360:1903-1913.

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NET REDUCTION IN SBP AND RELATIVE REDUCTION

IN STROKE

10 mm Hg greater lowering in SBP would be associated

with a reduction in risk of stroke of 31 %
Lawes C, Bennet DA.Stroke 2004 ;35:776-785
15
Prospective Studies Collaboration. Lancet 2002;360:1903-1913.

HTN effects on the cerebral circulation

HYPERTROPHY AND REMODELLING

ANGIOTENSIN II
ALTERS AUTOREGULATION
INHIBITS ENDOTELIUM
DEPENDENT RELAXATION
DISRUPTS BBB

Iadecola, Gorelick .Stroke .2004;35:348-350

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Angiotensin II

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Recommendations for 1o stroke prevention

1.

2.

3.

In agreement with the JNC 7 report, regular BP screening

and appropriate treatment, including both lifestyle
modification and pharmacological therapy,are
recommended (Class I; Level of Evidence A)
Systolic BP should be treated to a goal of <140 mm Hg
and diastolic BP to <90 mm Hg because these levels are
associated with a lower risk of stroke and cardiovascular
events (Class I; Level of Evidence A). In patients with
hypertension with diabetes or renal disease, the BP goal is
<130/ 80 mm Hg (also see section on diabetes)
(ClassI;Level of Evidence A).
Treatment of hypertension with diabetes with an ACEI or
and ARB is useful (Class I; level of Evidence A)
Guidelines for the Primary Prevention of Stroke. A Guideline for
HealthcareProfessionals From the American Heart Association/American
Stroke Association 2010
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Recommendations for 2o stroke prevention

1. BP reduction is recommended for both prevention of recurrent
stroke and prevention of other vascular events in persons who
have had an ischemic stroke or TIA and are beyond the first 24
hours (Class I; Level of Evidence A).
2. Because this benefit extends to persons with and without a
documented history of hypertension, this recommendation is
reasonable for all patients with ischemic stroke or TIA who are
considered appropriate for BP reduction (Class IIa; Level of
Evidence B).
3. An absolute target BP level and reduction are uncertain and
should be individualized, but benefit has been associated with
an average reduction of approximately 10/5 mm Hg, and
normal BP levels have been defined as <120/80 mm Hg by
JNC 7 (Class IIa; Level of Evidence B).
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The optimal drug regimen to achieve the recommended level of

reduction is uncertain because direct comparisons between
regimens are limited. The available data indicate that diuretics
or the combination of diuretics and an ACEI are useful (Class I;
Level of Evidence A). Class I; Level A
The choice of specific drugs and targets should be
individualized on the basis of pharmacological properties,
mechanism of action, and consideration of specific patient
characteristics for which specific agents are probably indicated
(eg, extracranial cerebrovascular occlusive disease, renal
impairment, cardiac disease, and diabetes) (Class IIa; Level of
Evidence B).

Guidelines for the Prevention of Stroke in Patients With Stroke or Transient Ischemic Attack
A Guideline for Healthcare Professionals From the American Heart Association/American
Stroke Association 2010

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Pengobatan pada Kondisi Tertentu

TERIMA KASIH

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