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|Main results||The estimated 10-year stroke risk was greater in hypertensive patients (23.7 ± 18.5%) than in patients with high blood pressure without known hypertension (12.4 ± 9.2%), or in normotensive subjects (5.3 ± 0.2%; p <0.001 for all comparisons) (Figure 1). In all 3 categories, stroke risk was significantly higher in men than in women (p <0.001).|
Figure 1. Estimated 10-year risk of stroke in Spanish subjects aged 60 years and older divided
into 3 blood pressure categories. Stroke risk was calculated using the Framingham stroke risk scale.1
This study confirms the importance of hypertension as a risk factor for stroke. It also confirms data from previous studies showing that Spain is one of the countries with the highest prevalence of hypertension and with the lowest rate of BP control.2 In the whole study population, only 35.7% of subjects presented BP values within controlled range. SBP was below therapeutic control threshold in 37.7% of cases, whereas DBP was below threshold in 71.6%. Only 29.1% of hypertensive subjects included in the study had their blood pressure at target level.
An unexpected result was that stroke risk was almost doubled in patients with diagnosed hypertension compared with those with undiagnosed hypertension. The authors stress that, compared with subjects with elevated BP but no diagnosed hypertension, those with diagnosed hypertension showed a significantly higher prevalence of other stroke risk factors (LVH, 16.9% versus 4.9%, p <0.001; diabetes mellitus, 31.4% versus 26.5%; p = 0.003; established cardiovascular disease, 36.4% versus 10.8%, p <0.001; and atrial fibrillation, 0.6% versus 3.0%, p <0.001). That implied, for one same BP level, an additional risk of stroke in those with HT diagnosed. The authors speculate that subjects with high BP but no diagnosed hypertension may recruit individuals with intermittent BP elevations, or with recent-onset hypertension not previously diagnosed.
Comprehensive preventive strategy warrantedStroke prevention has become a major public health challenge, especially in consideration of the population aging that is expected to continue in the near future. The results of this study are a call to better prevention of stroke through better detection of hypertension and better control of blood pressure in elderly individuals. As stressed by the authors, however, the Framingham stroke risk indicator does not consider the potential impact of some documented risk factors for stroke. For example, the SPARCL trial reported significant benefits of intensive LDL-lowering pharmacotherapy in secondary prevention of cerebrovascular events (stroke and AIT).3 Subanalyses of the SPARCL data showed that low HDL cholesterol levels at baseline were associated with a large percentage of the residual risk of stroke persisting even after aggressive statin therapy.4 Effective stroke prevention cannot be based on blood pressure control only. The most effective strategy for stroke prevention is a comprehensive approach aiming at detecting and controlling all known modifiable stroke risk factors at the individual level.