Hypertension Is Significantly Undertreated in Those With History of Stroke

Future studies are needed to determine the preferential antihypertensive medication in patients after experiencing a stroke, despite the results suggesting a gap in secondary prevention of stroke.

Mandip S. Dhamoon, MD, DrPH

Mandip S. Dhamoon, MD, DrPH

Data from the National Health and Nutrition Examination Survey (NHANES) cross-sectional analysis suggested that there is a substantial undertreatment of hypertension in individuals with a history of stroke, and that more than one-third of patients had uncontrolled hypertension.

The cross-sectional surveys, conducted between 2005 and 2016, included 4,971,136 individuals with a history of stroke and hypertension and summarized the number and classes of antihypertensive medications, frequency of uncontrolled hypertension, and associations between antihypertensive classes and blood pressure control.

Analyzed from March 2019 to January 2020, the results showed that 37.1% (95% CI, 33.5—40.8) of patients had uncontrolled blood pressure at examination, with 80.4% (95% CI , 82.0–87.5) of those taking antihypertensive medication. In comparison, individuals with controlled blood pressure were more likely to be taking any antihypertensive medication across class type, except for calcium channel blockers (CCBs; controlled: 29.9%; uncontrolled: 34.3%) and other hypertensive classes (controlled: 3.9%; uncontrolled: 6.3%), which were more common among individuals with uncontrolled blood pressure.

Controlled blood pressure was observed in 64.7% of individuals taking antihypertensive medication. Although no class of hypertensive medication had statistically significant higher frequency of blood pressure control, diuretics (65.9%) and thiazides (70.5%) had the highest frequency of blood pressure control. CCBs (59.6%) or other antihypertensive classes (51.2%) had the lowest frequency of blood pressure control.

Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB; 59.2%; 95% CI, 54.9—63.4) and ß-blockers (43.8%; 95% CI, 40.3–47.3) were among the most commonly used antihypertensive medications. Diuretics (41.6%; 95% CI, 37.3–45.9) and CCBs (31.5%; 95% CI 28.2%–34.8%) were among other commonly used antihypertensive medications recorded. Individuals taking more than 1 antihypertensive medication made up 56.7% of the patient population (95% CI, 52.8%–60.6%) compared to 28% (95% CI, 24.6%–31.5%) who were taking only 1.

The study authors, Mandip S. Dhamoon, MD, DrPH, associate professor of neurology, Icahn School of Medicine at Mount Sinai, and Daniel Santos, MD, neurologist, Icahn School of Medicine at Mount Sinai, also observed that diuretics have become significantly less commonly used from 2005—2006 (49.4%) compared to 2015–2016 (35.7%; P = .005), though the frequencies of other antihypertensive classes remained consistent. They also noted that antihypertensive medications, specifically ß-blockers, are frequently prescribed for indications other than hypertension and therefore may have an impact on the medication trends observed.

“Because hypertension is a major risk factor for stroke, these data demonstrate a missed opportunity nationally for secondary stroke prevention,” Dhamoon and Santos wrote.

Hypertension was defined by self-report, antihypertensive medication use, or uncontrolled blood pressure (>140/90 mm Hg) on physical examination. Antihypertensive medication was classified as either angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, diuretics, B-blockers, calcium channel blockers, or other. The mean age of individuals within the study was 67.1 years (95% CI, 66.1—68.1), and 2,790,518 (56.1%) were women. Additionally, the mean blood pressure was 134/68 (95% CI, 133/67 to 136/69) mm Hg, and the mean number of antihypertensive medications was 1.8 (95% CI, 1.7–1.9).

Dhamoon and colleagues concluded that “although this study reveals a gap in secondary prevention of stroke, future studies are needed to determine preferential antihypertensive medication in patients after stroke. Studies focused on the efficacy of the class and number of antihypertensive medications in this patient population may be particularly beneficial.”


Santos D, Dhamoon MS. Trends in antihypertensive medication use among individuals with a history of stroke and hypertension, 2005 to 2016. JAMA Neurol. Published online July 27, 2020. doi: 10.1001/jamaneurol.2020.2499

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