Hypertension and Stroke

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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
3 mmHg SBP 10 mmHg SBP
reduction reduction
Systolic blood pressure

35% Stroke risk

20% to 30%. reduction in
Stroke risk subjects aged
reduction 60 to 69 years

A meta-analysis of Two cohort study

nine randomized overviews
comparative trials
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 5

 Terms and Conditions
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Source: The Lancet Neurology 2009; 8:345-354 (DOI:10.1016/S1474-4422(09)70023-7)
OUTCOMES AFTER ISCHEMIC STROKE
___________________________________
Stroke recurrence Functional Disability
30 day 3 % - 10 % 24 53 % of stroke
1 year 5 % - 14 % survivor with complete or
5 year 25 % - 40 % partial dependences
Quality of life decrease in
Mortality 27 %
30 day 8 20 % Dementia or cognitive
decline 34 % at 52 week
1 year 15 25 %
post stroke
5 year 40 60 %
Sacco RL . Neuroloy 1997;49:S19-S44
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RISK FACTOR OF STROKE AND CAD

STROKE CAD

HYPERTENSION

DISLIPIDEMIA

VASCULAR DISEASES

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 THE POPULATION-ATTRIBUTABLE RISK OF
COMMON RISK FACTORS

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

:74-75 9
 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 15,4 %

Age 45-54 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
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Prospective Studies Collaboration.
. Lancet 2002;360:1903-1913.
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
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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. 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)
2. 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).
3. 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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