Optimal target blood pressure for the primary prevention of hemorrhagic stroke: a nationwide observational study

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Optimal target blood pressure for the primary prevention of hemorrhagic stroke: a nationwide observational study

Hwan Seok Shim^‡ Jeong-Mee Park^†‡ Yong Jae Lee Young-Deok Kim Tackeun Kim Seung Pil Ban Jae Seung Bang O-Ki Kwon Chang Wan Oh Si Un Lee^*

• Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Republic of Korea

Background: There are few reports on the preventative value of intensive blood pressure (BP) management for stroke, especially hemorrhagic stroke (HS), after new criteria for hypertension (HTN) were announced by the American College of Cardiology/American Heart Association in 2017.

Aims: This study aimed to identify the optimal BP for the primary prevention of HS in a healthy population aged between 20 and 65 years.

Methods: We conducted a 10-year observational study on the risk of HS, subclassified as intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) according to BP categories (e.g., low normal BP, high normal BP, elevated BP, stage 1 HTN, and stage 2 HTN) using the National Health Insurance Service Database.

Results: Out of 8,327,751 participants who underwent a health checkup in 2008, 949,550 were included in this study and observed from 2009 to 2018. The risk of ICH was significantly increased in men with stage 2 HTN {adjusted hazard ratio [aHR] 2.002 [95% confidence interval (CI) 1.203–3.332]} and in women with stage 1 HTN [aHR 2.021 (95% CI, 1.251–3.263)]. The risk of SAH was significantly increased in both men [aHR 1.637 (95% CI, 1.066–2.514)] and women [aHR 4.217 (95% CI, 2.648–6.715)] with stage 1 HTN. Additionally, the risk of HS was significantly increased in men with stage 2 HTN [aHR 3.034 (95% CI, 2.161–4.260)] and in women with stage 1 HTN [aHR 2.976 (95% CI, 2.222–3.986)].

Conclusion: To prevent primary HS, including ICH and SAH, BP management is recommended for adults under the age of 65 years with stage 1 HTN.

Introduction

The incidence and diagnosis rates of cerebrovascular diseases related to stroke are increasing as the population ages and diagnostic technology is developed (1–3). Accordingly, the demand for research on the primary or secondary prevention of stroke is also increasing. Among the modifiable risk factors for stroke, hypertension (HTN) is an important common factor in several studies (4). In 2017, the American College of Cardiology/American Heart Association (ACC/AHA) released an updated guideline with new criteria for HTN, defining stage 1 HTN as a systolic blood pressure (BP) of 130–139 mm Hg or a diastolic BP as 80–89 mm Hg (5).

However, although several studies have reported new diagnostic criteria for HTN that lower the incidence of various cardiovascular events (CVEs) (6–8), there are few helpful reports on the prevention of stroke. Some studies reported that intensive BP control prevents secondary stroke (3, 9, 10), but few studies reported a significant correlation with primary stroke prevention (8). Studies reporting that intensive BP control helps prevent primary stroke have limitations in that they include only patients with specific diseases, such as diabetes, or subgroup analysis, such as for hemorrhagic or ischemic stroke, was not conducted (9).

Therefore, we conducted a large-scale observational study on the risk of hemorrhagic stroke (HS), subclassified as subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH) according to BP based on the new diagnostic criteria for HTN in a healthy population using a nationwide cohort.

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