The PROGRESS trial three years later: time for a balanced report of effectiveness

The debate of how to manage blood pressure (BP) after stroke has been
going on for years and will probably continue for many more, as new agents
and regimens are being developed and tested (e.g. combining ACE Inhibitors
and Angiotensin Receptor Antagonists). Whilst these academic debates and
new clinical trials take place, it is vital for clinicians to concentrate
on the patient in front of them, and tailor the BP lowering regimen
according to the patient's clinical background and co-morbidities.

For the majority of patients, it is probably appropriate to lower the
BP as much as possible, as long as it can be safely tolerated. However,
some patients may not warrant such an aggressive regimen, e.g. those with
bilateral severe carotid stenosis [1], or those with a history of falls
due to orthostatic hypotension. Some groups of patients may particularly
warrant an ACE Inhibitor, such as those who have a history of myocardial
infarction, cardiac failure, diabetes [2], or stable coronary heart
disease [3]. On the other hand, diuretics should be used with caution or
avoided in certain groups of patients such as those with urinary
incontinence or poor renal function.

Some clinicians might choose Perindopril purely for its
pharmacological properties (e.g. its high trough-peak ratio and ease of
dose escalation) [4]. Indpamide is also meant to have a different
pharmacological profile from Thiazides [5], but no head-to-head comparison
trials have yet been performed amongst stroke patients. Clinicians might
also choose other ACE Inhibitors and diuretics for other reasons in order
to suit the patient in front of them.

MacMahon et al [6] and Rodgers [7] are correct in emphasising the
importance of not delaying the implementation of effective BP lowering for
all stroke patients. Due to the complexity and diversity of the patient
group, clinicians need to be clever in exercising the art of medicine to
find the appropriate regimen for each patient.

References:

1. Rothwell PM, et al; Carotid Endarterectomy Trialists'
Collaboration. Relationship between blood pressure and stroke risk in
patients with symptomatic carotid occlusive disease. Stroke
2003;34(11):2583-90.

2. Ruggenenti P, et al; Bergamo Nephrologic Diabetes Complications
Trial (BENEDICT) Investigators. Preventing microalbuminuria in type 2
diabetes. N Engl J Med 2004;351(19):1941-51.

3. Fox KM; EURopean trial On reduction of cardiac events with
Perindopril in stable coronary Artery disease Investigators. Efficacy of
perindopril in reduction of cardiovascular events among patients with
stable coronary artery disease: randomised, double-blind, placebo-
controlled, multicentre trial (the EUROPA study). Lancet
2003;362(9386):782-8.

4. Sica DA. Dosage considerations with perindopril for systemic
hypertension. Am J Cardiol 2001;88(7A):13i-18i.

5. Ames RP. A comparison of blood lipid and blood pressure responses
during the treatment of systemic hypertension with indapamide and with
thiazides. Am J Cardiol 1996;77(6):12b-16b.

6. MacMahon S, et al. The PROGRESS trial three years later: time for
more action, less distraction. BMJ 2004;329:970-971.

7. Rodgers H. The PROGRESS trial three years later: All aspects of
secondary prevention after stroke need to be improved. BMJ 2004;329:1404-
1405.

Competing interests:
Dr Joseph Kwan has received one lecture fee from Servier in 2002.