Telmisartan to prevent recurrent stroke and cardiovascular events.
BACKGROUND
Prolonged lowering of blood pressure after a stroke reduces the risk of recurrent stroke. In addition, inhibition of the renin-angiotensin system in high-risk patients reduces the rate of subsequent cardiovascular events, including stroke. However, the effect of lowering of blood pressure with a renin-angiotensin system inhibitor soon after a stroke has not been clearly established. We evaluated the effects of therapy with an angiotensin-receptor blocker, telmisartan, initiated early after a stroke.


METHODS
In a multicenter trial involving 20,332 patients who recently had an ischemic stroke, we randomly assigned 10,146 to receive telmisartan (80 mg daily) and 10,186 to receive placebo. The primary outcome was recurrent stroke. Secondary outcomes were major cardiovascular events (death from cardiovascular causes, recurrent stroke, myocardial infarction, or new or worsening heart failure) and new-onset diabetes.


RESULTS
The median interval from stroke to randomization was 15 days. During a mean follow-up of 2.5 years, the mean blood pressure was 3.8/2.0 mm Hg lower in the telmisartan group than in the placebo group. A total of 880 patients (8.7%) in the telmisartan group and 934 patients (9.2%) in the placebo group had a subsequent stroke (hazard ratio in the telmisartan group, 0.95; 95% confidence interval [CI], 0.86 to 1.04; P=0.23). Major cardiovascular events occurred in 1367 patients (13.5%) in the telmisartan group and 1463 patients (14.4%) in the placebo group (hazard ratio, 0.94; 95% CI, 0.87 to 1.01; P=0.11). New-onset diabetes occurred in 1.7% of the telmisartan group and 2.1% of the placebo group (hazard ratio, 0.82; 95% CI, 0.65 to 1.04; P=0.10).


CONCLUSIONS
Therapy with telmisartan initiated soon after an ischemic stroke and continued for 2.5 years did not significantly lower the rate of recurrent stroke, major cardiovascular events, or diabetes. (ClinicalTrials.gov number, NCT00153062.)
Yusuf
Salim
S
Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
Diener
Hans-Christoph
HC
Sacco
Ralph L
RL
Cotton
Daniel
D
Ounpuu
Stephanie
S
Lawton
William A
WA
Palesch
Yuko
Y
Martin
Reneé H
RH
Albers
Gregory W
GW
Bath
Philip
P
Bornstein
Natan
N
Chan
Bernard P L
BP
Chen
Sien-Tsong
ST
Cunha
Luis
L
Dahlöf
Björn
B
De Keyser
Jacques
J
Donnan
Geoffrey A
GA
Estol
Conrado
C
Gorelick
Philip
P
Gu
Vivian
V
Hermansson
Karin
K
Hilbrich
Lutz
L
Kaste
Markku
M
Lu
Chuanzhen
C
Machnig
Thomas
T
Pais
Prem
P
Roberts
Robin
R
Skvortsova
Veronika
V
Teal
Philip
P
Toni
Danilo
D
VanderMaelen
Cam
C
Voigt
Thor
T
Weber
Michael
M
Yoon
Byung-Woo
BW