An optimum blood pressure target after lacunar stroke?

482 www.thelancet.com Vol 382 August 10, 2013 Sustained lowering of blood pressure by 10 mm Hg systolic and 5 mm Hg diastolic lessens the risk of recurrent stroke by about one-third (relative risk 0·66, 95% CI 0·56–0·79). Larger reductions in blood pressure are associated with greater reductions in risk. This eff ect is consistent in most subtypes of stroke because hypertension-induced intracranial aneurysms and intracranial small-artery disease are major risk factors for haemorrhagic stroke, and hypertension-induced atrial fi brillation, atherosclerosis, and intra cranial small-artery disease are major risk factors for ischaemic stroke. The blood-pressure range within which the association with stroke risk remains linear, however, is uncertain. In some stroke patients, such as those with severe, bilateral carotid or vertebrobasilar occlusive disease, lowering of systolic blood pressure to less than 150 mm Hg raises the risk of stroke owing to loss of autoregulation of intracranial arteries and thus the maintenance of cerebral perfusion below a certain pressure threshold. For each stroke patient there is likely to be a lower range of blood pressure in which the benefi ts of lowering pressure in the prevention of recurrent stroke are maximised before the risks of haemodynamic stroke increase. Whether an optimum target range exists is unknown; stroke guidelines merely state that an absolute target for blood pressure reduction is uncertain and should be managed on an individual basis. In The Lancet, the SPS3 Study Group report on a randomised trial in which they investigated whether a target systolic blood pressure of less than 130 mm Hg is safe and more eff ective than a target range of 130–149 mm Hg in patients with recent but non-acute stroke. Among 3020 patients with subcortical lacunar ischaemic stroke in the preceding 2 weeks to 6 months, 95% in each treatment group achieved their allocated target systolic blood pressure at least once, as measured An optimum blood pressure target after lacunar stroke? especially in low-income and middle-income countries, which have 80% of the burden of non-communicable diseases. Governments have the primary responsibility for ensuring that appropriate institutional, legal, and fi nancial arrangements are provided. WHO will work with Ministries of Health, UN agencies, and inter national and national partners—including civil society—to implement the plan. Data collected from all countries to track national, regional, and global progress will be presented to the World Health Assembly in 2016, 2021, and 2026. For all countries, the cost of inaction far outweighs the cost of action. However, eff ective implementation of the plan faces many challenges: reliable data on risk factors and mortality are needed, human and fi nancial resources are often inadequate, and some health systems are weak. For countries with limited resources, phased scale-up of the most cost-eff ective interventions could be prioritised. Such interventions can greatly reduce the burden of non-communicable diseases and yet can be aff orded by all countries. To implement such interventions, current health spending needs to increase by 4% in low-income countries, 2% in lower middleincome countries, and less than 1% in upper middleincome countries. For low-income countries, national spending on health might need to be supplemented with funding from international partners and development agencies. WHO will strive to assist countries to overcome the challenges and provide technical support to launch a sustainable and pragmatic national response to realise the vision of the action plan: “a world free of the avoidable burden of non-communicable diseases”.