Lüders Stephan
Medizinische Klinik, St. Josefs-Hospital, Cloppenburg, Germany.
Drugs. 2007;67(7):955-63. doi: 10.2165/00003495-200767070-00001.
Hypertension is the major risk factor for ischaemic and haemorrhagic clinical strokes as well as for silent brain infarcts with a continuous association between both systolic and diastolic blood pressures. Epidemiological data highlight the increasing burden to come over the next decades. Without any doubt, antihypertensive treatment is the most important therapy to reduce the risk of stroke by approximately 30-40%. International guidelines recommend antihypertensive treatment for primary prevention with evidence level A. Recurrent strokes or transient ischaemic attack (TIA) are an important practical, clinical and economic problem, and have a major impact on the development of vascular dementia. All stroke patients and patients with TIA have to be regarded as very high-risk patients. Hypertension increases the risk of recurrent strokes. Only limited data directly address the role of blood pressure treatment among individuals with stroke or TIA. There is a general lack of definitive data regarding when to start antihypertensive treatment in the initial phase, and treatment of hypertension in the acute period after stroke is still under debate. Experimental and clinical data suggest that reducing the activity of the renin-angiotensin aldosterone system (RAAS) may have beneficial effects beyond the lowering of blood pressure. There is increasing evidence of cerebroprotective effects for medication influencing the RAAS, such as angiotensin receptor antagonists or ACE inhibitors. The MOSES study showed for the first time superiority of an angiotensin receptor antagonist compared with a calcium channel antagonist in antihypertensive treatment for secondary stroke prevention. Optimal blood pressure range in secondary prevention seems to be 120-140/80-90 mm Hg, but questions about a J- or U-shaped curve are still not answered sufficiently. The effects of additional antihypertensive treatment in the evening for stroke patients with 'non-dipping' blood pressure need to be investigated.Currently, the most important goal in primary and secondary prevention of stroke is a strict normotensive blood pressure control. Antihypertensive treatment is recommended for both prevention of recurrent stroke and prevention of other vascular events in individuals who have had an ischaemic stroke or TIA (class I, level of evidence A). Many open questions remain and funding of stroke research needs to be increased in the near future.
高血压是缺血性和出血性临床中风以及无症状脑梗死的主要危险因素，收缩压和舒张压之间存在持续关联。流行病学数据凸显了未来几十年负担将不断加重。毫无疑问，降压治疗是降低中风风险约30%-40%的最重要疗法。国际指南推荐进行证据等级为A的一级预防降压治疗。复发性中风或短暂性脑缺血发作（TIA）是一个重要的实际、临床和经济问题，对血管性痴呆的发展有重大影响。所有中风患者和TIA患者都必须被视为极高风险患者。高血压会增加复发性中风的风险。只有有限的数据直接涉及中风或TIA患者的血压治疗作用。关于在初始阶段何时开始降压治疗普遍缺乏确凿数据，而且中风急性期的高血压治疗仍存在争议。实验和临床数据表明，降低肾素-血管紧张素-醛固酮系统（RAAS）的活性可能除了降低血压外还有有益作用。越来越多的证据表明，影响RAAS的药物如血管紧张素受体拮抗剂或ACE抑制剂具有脑保护作用。MOSES研究首次表明，在二级中风预防的降压治疗中，血管紧张素受体拮抗剂优于钙通道拮抗剂。二级预防中的最佳血压范围似乎是120-140/80-90 mmHg，但关于J形或U形曲线的问题仍未得到充分解答。需要研究夜间额外降压治疗对血压“非勺型”的中风患者的影响。目前，中风一级和二级预防的最重要目标是严格将血压控制在正常范围内。对于曾发生缺血性中风或TIA的个体，推荐进行降压治疗以预防复发性中风和其他血管事件（I类，证据等级A）。许多悬而未决的问题仍然存在，近期需要增加中风研究的资金投入。
