title: Achieved Blood Pressure and Outcomes in the Secondary Prevention of Small Subcortical Strokes Trial.
abstract: Studies suggest a J-shaped association between blood pressure and cardiovascular events in the setting of intensive systolic blood pressure control; whether there is a similar association with stroke remains less well established. The Secondary Prevention of Small Subcortical Strokes was a randomized trial to evaluate higher (130-149 mm Hg) versus lower (<130 mm Hg) systolic blood pressure targets in participants with recent lacunar infarcts. We evaluated the association of mean achieved blood pressure, 6 months after randomization, and recurrent stroke, major vascular events, and all-cause mortality. After a mean follow up of 3.7 years, there was a J-shaped association between achieved blood pressure and outcomes; the lowest risk was at ≈124 and 67 mm Hg systolic and diastolic blood pressure, respectively. For example, above a systolic blood pressure of 124 mm Hg, 1 standard deviation higher (11.1 mm Hg) was associated with increased mortality (adjusted hazard ratio: 1.9; 95% confidence interval: 1.4, 2.7), whereas below this level, this relationship was inverted (0.29; 0.10, 0.79), P<0.001 for interaction. Above a diastolic blood pressure of 67 mm Hg, a 1 standard deviation higher (8.2 mm Hg) was associated with an increased risk of stroke (2.2; 1.4, 3.6), whereas below this level, the association was in the opposite direction (0.34; 0.13, 0.89), P=0.02 for interaction. The lowest risk of all events occurred at a nadir of ≈120 to 128 mm Hg systolic blood pressure and 65 to 70 mm Hg diastolic blood pressure. Future studies should evaluate the impact of excessive blood pressure reduction, especially in older populations with preexisting vascular disease.
  
  
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  URL: http://www.clinicaltrials.gov. Unique identifier: NCT00059306.
authors.affiliation: From the School of Biological and Population Health Sciences, Oregon State University, Corvallis (M.C.O.); Department of Biostatistics, University of Alabama at Birmingham (L.A.M.); Division of Nephrology, Department of Internal Medicine, Bone and Mineral Metabolism, University of Kentucky, Lexington (B.P.S.); Department of Health Restoration and Care Systems Management, School of Nursing, University of Texas Health Science Center, San Antonio (C.L.W.); Department of Medicine, University of California, San Francisco (C.A.P.); Center for Brain Health, Department of Medicine, University of British Columbia, Vancouver, Canada (T.S.F., O.R.B.); Population Health Research Institute, Hamilton, CA (R.G.H.); and Renal Associates PA, San Antonio, TX (P.E.P.). Michelle.Odden@oregonstate.edu.
authors.forename: Michelle C
authors.initials: MC
authors.lastname: Odden
authors.affiliation: From the School of Biological and Population Health Sciences, Oregon State University, Corvallis (M.C.O.); Department of Biostatistics, University of Alabama at Birmingham (L.A.M.); Division of Nephrology, Department of Internal Medicine, Bone and Mineral Metabolism, University of Kentucky, Lexington (B.P.S.); Department of Health Restoration and Care Systems Management, School of Nursing, University of Texas Health Science Center, San Antonio (C.L.W.); Department of Medicine, University of California, San Francisco (C.A.P.); Center for Brain Health, Department of Medicine, University of British Columbia, Vancouver, Canada (T.S.F., O.R.B.); Population Health Research Institute, Hamilton, CA (R.G.H.); and Renal Associates PA, San Antonio, TX (P.E.P.).
authors.forename: Leslie A
authors.initials: LA
authors.lastname: McClure
authors.affiliation: From the School of Biological and Population Health Sciences, Oregon State University, Corvallis (M.C.O.); Department of Biostatistics, University of Alabama at Birmingham (L.A.M.); Division of Nephrology, Department of Internal Medicine, Bone and Mineral Metabolism, University of Kentucky, Lexington (B.P.S.); Department of Health Restoration and Care Systems Management, School of Nursing, University of Texas Health Science Center, San Antonio (C.L.W.); Department of Medicine, University of California, San Francisco (C.A.P.); Center for Brain Health, Department of Medicine, University of British Columbia, Vancouver, Canada (T.S.F., O.R.B.); Population Health Research Institute, Hamilton, CA (R.G.H.); and Renal Associates PA, San Antonio, TX (P.E.P.).
authors.forename: B Peter
authors.initials: BP
authors.lastname: Sawaya
authors.affiliation: From the School of Biological and Population Health Sciences, Oregon State University, Corvallis (M.C.O.); Department of Biostatistics, University of Alabama at Birmingham (L.A.M.); Division of Nephrology, Department of Internal Medicine, Bone and Mineral Metabolism, University of Kentucky, Lexington (B.P.S.); Department of Health Restoration and Care Systems Management, School of Nursing, University of Texas Health Science Center, San Antonio (C.L.W.); Department of Medicine, University of California, San Francisco (C.A.P.); Center for Brain Health, Department of Medicine, University of British Columbia, Vancouver, Canada (T.S.F., O.R.B.); Population Health Research Institute, Hamilton, CA (R.G.H.); and Renal Associates PA, San Antonio, TX (P.E.P.).
authors.forename: Carole L
authors.initials: CL
authors.lastname: White
authors.affiliation: From the School of Biological and Population Health Sciences, Oregon State University, Corvallis (M.C.O.); Department of Biostatistics, University of Alabama at Birmingham (L.A.M.); Division of Nephrology, Department of Internal Medicine, Bone and Mineral Metabolism, University of Kentucky, Lexington (B.P.S.); Department of Health Restoration and Care Systems Management, School of Nursing, University of Texas Health Science Center, San Antonio (C.L.W.); Department of Medicine, University of California, San Francisco (C.A.P.); Center for Brain Health, Department of Medicine, University of British Columbia, Vancouver, Canada (T.S.F., O.R.B.); Population Health Research Institute, Hamilton, CA (R.G.H.); and Renal Associates PA, San Antonio, TX (P.E.P.).
authors.forename: Carmen A
authors.initials: CA
authors.lastname: Peralta
authors.affiliation: From the School of Biological and Population Health Sciences, Oregon State University, Corvallis (M.C.O.); Department of Biostatistics, University of Alabama at Birmingham (L.A.M.); Division of Nephrology, Department of Internal Medicine, Bone and Mineral Metabolism, University of Kentucky, Lexington (B.P.S.); Department of Health Restoration and Care Systems Management, School of Nursing, University of Texas Health Science Center, San Antonio (C.L.W.); Department of Medicine, University of California, San Francisco (C.A.P.); Center for Brain Health, Department of Medicine, University of British Columbia, Vancouver, Canada (T.S.F., O.R.B.); Population Health Research Institute, Hamilton, CA (R.G.H.); and Renal Associates PA, San Antonio, TX (P.E.P.).
authors.forename: Thalia S
authors.initials: TS
authors.lastname: Field
authors.affiliation: From the School of Biological and Population Health Sciences, Oregon State University, Corvallis (M.C.O.); Department of Biostatistics, University of Alabama at Birmingham (L.A.M.); Division of Nephrology, Department of Internal Medicine, Bone and Mineral Metabolism, University of Kentucky, Lexington (B.P.S.); Department of Health Restoration and Care Systems Management, School of Nursing, University of Texas Health Science Center, San Antonio (C.L.W.); Department of Medicine, University of California, San Francisco (C.A.P.); Center for Brain Health, Department of Medicine, University of British Columbia, Vancouver, Canada (T.S.F., O.R.B.); Population Health Research Institute, Hamilton, CA (R.G.H.); and Renal Associates PA, San Antonio, TX (P.E.P.).
authors.forename: Robert G
authors.initials: RG
authors.lastname: Hart
authors.affiliation: From the School of Biological and Population Health Sciences, Oregon State University, Corvallis (M.C.O.); Department of Biostatistics, University of Alabama at Birmingham (L.A.M.); Division of Nephrology, Department of Internal Medicine, Bone and Mineral Metabolism, University of Kentucky, Lexington (B.P.S.); Department of Health Restoration and Care Systems Management, School of Nursing, University of Texas Health Science Center, San Antonio (C.L.W.); Department of Medicine, University of California, San Francisco (C.A.P.); Center for Brain Health, Department of Medicine, University of British Columbia, Vancouver, Canada (T.S.F., O.R.B.); Population Health Research Institute, Hamilton, CA (R.G.H.); and Renal Associates PA, San Antonio, TX (P.E.P.).
authors.forename: Oscar R
authors.initials: OR
authors.lastname: Benavente
authors.affiliation: From the School of Biological and Population Health Sciences, Oregon State University, Corvallis (M.C.O.); Department of Biostatistics, University of Alabama at Birmingham (L.A.M.); Division of Nephrology, Department of Internal Medicine, Bone and Mineral Metabolism, University of Kentucky, Lexington (B.P.S.); Department of Health Restoration and Care Systems Management, School of Nursing, University of Texas Health Science Center, San Antonio (C.L.W.); Department of Medicine, University of California, San Francisco (C.A.P.); Center for Brain Health, Department of Medicine, University of British Columbia, Vancouver, Canada (T.S.F., O.R.B.); Population Health Research Institute, Hamilton, CA (R.G.H.); and Renal Associates PA, San Antonio, TX (P.E.P.).
authors.forename: Pablo E
authors.initials: PE
authors.lastname: Pergola
mesh_terms: D001241:Aspirin / Q000627:therapeutic use*; D001794:Blood Pressure / Q000502:physiology*; D001795:Blood Pressure Determination; D000077144:Clopidogrel; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D006973:Hypertension / Q000150:complications / Q000188:drug therapy* / Q000503:physiopathology; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D012008:Recurrence; D055502:Secondary Prevention / Q000379:methods*; D012720:Severity of Illness Index; D059409:Stroke, Lacunar / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control*; D013988:Ticlopidine / Q000031:analogs & derivatives* / Q000627:therapeutic use; D016896:Treatment Outcome
chemical_list: D010975:Platelet Aggregation Inhibitors; D000077144:Clopidogrel; D013988:Ticlopidine; D001241:Aspirin
keywords: aged; antihypertensive agents; blood pressure; secondary prevention; stroke