Secondary prevention of stroke by blood pressure-lowering treatment

High blood pressure is the most important modifiable risk factor for stroke, accounting for more than 50% of the population-attributable fraction for stroke. There is now strong evidence from randomized trials that blood pressure-lowering treatment is one of the most effective and generalizable strategies for secondary prevention of stroke. Once the patient with stroke has stabilized, all patients should receive blood pressure-lowering therapy, irrespective of their blood pressure levels. Combination therapy with an angiotensin-converting enzyme (ACE) inhibitor plus a diuretic is an established regimen, but an angiotensin II-receptor blocker may provide an alternative regimen in patients who do not tolerate an ACE inhibitor, especially in combination with a diuretic. For patients with previous stroke, goal blood pressures of < 130/80 mm Hg in hypertensive subjects and < 120/80 mm Hg in normotensive (or "prehypertensive") subjects should be achieved using combination blood pressure-lowering therapy.