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Blood Pressure vs 2nd Stroke: Lower isn't Better

Posted Nov 18 2011 3:01am
Ouch!  I'm going through a mid-life crisis of sorts.  8 years ago when I was recruited to Sin City, the mantra was lower is better.  Lower blood pressure, lower cholesterol, lower glucose (HgbA1c).  All this got tossed out with the ACCORD trial back in 2008 with different subset analyses published more recently  which demonstrated that lower blood pressure, cholesterol & glucose did not affect outcomes in diabetics.  In other words, lower isn't always better.

When it comes to primary prevention of strokes, lower blood pressure has always been key.  This was confirmed just under 2 months ago in a large meta-analysis demonstrating that even pre-hypertension is associated with an increase risk of initial (incident) stroke.

But in a surprising turn around (surprising, at least, to me), JAMA released an observational study this week  in which 20,330 patients who'd had a recent stroke were followed for 2+yrs after which the authors concluded that those with a systolic blood pressure of 130-140mm Hg had the lowest risk of recurrent stroke, compared to both very low normal (<120mm Hg), low normal (120-130mm Hg), high (140-150mm Hg), and very high (>150mm Hg) blood pressure.  
Remember, this was an observational study.  Moreover, it was a post-hoc analysis.  In other words, the original authors weren't even looking for this finding in the original study.  Therefore, the conclusion is only good for generating hypotheses, not for dictating care guidelines.  But in a broad sense, it's certainly consistent with the ACCORD findings that we don't necessarily have to strive for the lowest.  So this is where the art of medicine kicks in . . .

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