Even patients with normal blood pressure and cholesterol levels may benefit

Two key trials—the perindopril protection against recurrent stroke study (PROGRESS)1 and the heart protection study (HPS)2—have expanded options for secondary prevention after stroke or transient ischaemic attack and have also mandated a fundamental change in thinking about risk. The concepts of hypertension and hypercholesterolaemia may now be irrelevant or even harmful in this population.^w1

In observational epidemiology studies no demonstrable floor exists for the relation between blood pressure and risk of stroke, with risk continuing to halve for every 10 mm Hg fall in diastolic pressure even at conventionally normotensive values.3 Meta-analyses of small trials of antihypertensive treatment in patients with a stroke showed a 28% reduction in relative risk for stroke regardless of baseline blood pressure.4 ^w2 This was supported by the post-stroke antihypertensive study (PATS),5 in which indapamide gave an absolute reduction in stroke risk by 2.9% compared with placebo over three years (number needed to treat (NNT) = 34) in 5665 patients with prior stroke or transient ischaemic attack and mean baseline blood pressure of 154/93 mm Hg.

In PROGRESS, 6105 patients who had had a stroke or transient ischaemic attack an average of six months previously were randomised to get 4 mg of perindopril, a long acting angiotensin converting enzyme (ACE) inhibitor prodrug, in combination with indapamide 2 mg or 2.5 mg …