Optimum Blood Pressure Target After Lacunar StrokeResponse to Optimum Blood Pressure Target After Lacunar Stroke: Con Side of the Argument
Con Side of the Argument
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The recent report of the Secondary Prevention of Small Subcortical Strokes (SPS3) trial, a randomized controlled clinical trial of secondary prevention of stroke targeting systolic blood pressures (BPs) <130 versus 130 to 149 mm Hg in patients with recent but not acute subcortical lacunar stroke,1 and the associated Comment2 conclude that “Although the reduction in stroke was not significant, our results support that in patients with recent lacunar stroke, the use of a systolic-blood-pressure target of less than 130 mm Hg is likely to be beneficial.”1 Indeed, the Comment underlined that “the SPS3 trial was underpowered to identify or exclude confidently a slight, but nevertheless clinically important, increase in serious complications of hypotension with systolic blood pressure lower than 130 mm Hg.”2 However, the cover of August 10 to 16, 2013 issue of The Lancet that carries the article on SPS3 and the associated Comment reads “The implications of SPS3 are that clinicians should endeavour to achieve and maintain systolic blood pressures lower than 130 mm Hg in patients who have survived 2 weeks or more after subcortical lacunar ischemic stroke.” This assertion is essentially based on the consistency of results across subgroups, the consistency of results (19% reduction in events) with other studies of primary or secondary prevention of different types of stroke, at similar differences of systolic BP between groups, in this particular trial 11 mm Hg between the achieved BP of the high-target group (138 mm Hg) and the low-target group (127 …