Optimal Blood Pressure and Cholesterol Targets for Preventing Recurrent Stroke in Hypertensives

• Status: Completed
• Trial end date: 2021-03-31
• Target enrollment: 0
• Participant gender: All

Summary

Stroke is one of the major causes not only of mortality, but of disease burden worldwide, because of residual disability and cognitive decline. Although blood pressure lowering has been clearly shown to be the most effective means for primary and secondary prevention of stroke, the systolic blood pressure (SBP) levels to achieve by treatment in order to optimize prevention results are unknown, and whether SBP levels lower than those usually recommended are accompanied by further or reduced benefits is undecided yet. Likewise, while low-density lipoprotein cholesterol (LDL-C) lowering by statins has been shown to be associated with primary and secondary stroke prevention, whether more intense lowering is or is not of further benefit is unknown. The Stroke in Hypertension Optimal Treatment Trial (ESH-CHL-SHOT) is a factorial 3 x 2 arm, multicenter, randomized clinical trial designed to test the hypothesis that in elderly patients at high risk of recurrent stroke (previous recent stroke or TIA) antihypertensive treatment programs aimed at reducing SBP to the usually recommended values (< 145 to 135 mmHg), to a lower goal (< 135 to 125 mmHg) or to even lower values (< 125 mmHg) will result in progressively greater reductions in recurrent stroke, incidence of cardiovascular outcomes and cognitive decline. Parallely, the preventive efficacy of more and less intense LDL-C reductions will be tested on the same outcomes.

• Phase: Phase 4
• Accepts Healthy Volunteers?: No

Details

• Lead Sponsor: Istituto Auxologico Italiano
• Collaborators: Chinese Hypertension League; European Society of Hypertension
• Treatments: Angiotensin Receptor Antagonists; Angiotensin-Converting Enzyme Inhibitors; Antihypertensive Agents; Atorvastatin; Calcium Channel Blockers; Diuretics; Enzyme Inhibitors; Mineralocorticoid Receptor Antagonists; Pravastatin; Rosuvastatin Calcium; Simvastatin; Sodium Chloride Symporter Inhibitors

Criteria

Inclusion Criteria:

• Qualifying event: stroke or TIA 1 to 6 months previous to randomization.

• All patients should have a CT scan or MRI (preferably MRI) at screening. The CT scan or MRI carried out at the time of the qualifying event, if available, is acceptable. Stroke will be defined as imaging evidence of a recent brain infarction (or haemorrhage) independently of duration of clinical symptoms, or as duration of clinical symptoms > 24 h even in absence of imaging evidence of lesion

• TIA as clinical symptoms (involving limbs or speech) lasting < 24 h without imaging evidence of infarction. Enrolling units should avoid enrolling patients with TIA in a proportion greater than 25% of enrolled patients. The general coordinators in Milan and Beijing may decide stopping enrolment of TIA patients if their proportion is becoming greater than expected.

• A haemorrhagic stroke (1 to 6 months previously) is also a qualifying event, but only for the BP-lowering component of the trial (see Exclusion criteria).

• Age: 65 years and above. No fixed upper age limit is introduced, but frail patients aged above 80 years should not be enrolled.

• Gender: either gender.

• BP: Only hypertensive patients: untreated patients with SBP ≥140 mmHg; patients on antihypertensive treatment with any BP (but see exclusion criteria)

• LDL-C: Patients without statin treatment with LDL-C > 2.8 mmol/l; patients on statin treatment with any LDL-C value (but see exclusion criteria)

• Antiplatelet therapy: All patients should be under antiplatelet therapy (agents and doses chosen by the investigator according to accepted guidelines), unless contraindicated. Anticoagulant (instead of antiplatelet) therapy whenever indicated (e.g. atrial fibrillation).

Exclusion Criteria:

• Qualifying event:

1. Patients in unstable clinical conditions

2. Clinical disturbances caused by non-stroke pathology

3. patients with haemodynamically significant carotid stenosis or requiring carotid revascularization

4. haemorrhagic stroke is an exclusion criterion for the lipid lowering component of the trial; however, these patients should be randomized to the BP component, but considered in addition to the number of patients requested to each enrolling unit, in order not to decrease the power of the lipid-lowering component.

• BP: - known secondary hypertension;

• SBP >140 mmHg under three antihypertensive drugs at full doses (these patients are unlikely to achieve SBP < 125 mmHg, if so randomized);

• orthostatic hypotension (SBP fall > 25 mmHg on standing);

• LDL-C: - LDL-C >2.8 mmol/l under full dose of a statin (these patients are unlikely to achieve LDL-C targets).

• LDL-C > 4.5 mmol/l under low dose of a statin or untreated (these patients are unlikely to achieve the lower LDL-C target).

• Others: - Patients with a myocardial infarction (preceding or subsequent to the qualifying stroke or TIA) if their baseline LDL-C is < 1.8 mmol/l

• Dementia

• Severe disability (modified Rankin scale > 4)

• Severe chronic renal failure defined as serum creatinine > 250 micromol/l

• Hepatic disease as determined by either AST or ALT values > 2 times the upper limit of normal

• History of hepatic encephalopathy, esophageal varices or portocaval shunt

• History of gastrointestinal surgery or disorders which could interfere with drug absorption

• Known allergy or contraindications to one of the drugs to be administered in the study

• History of malignancy including leukaemia and lymphoma (but not basal cell skin cancer) within the last 5 years

• History of clinically significant autoimmune disorders such as systemic lupus erythematosus

• History of drug or alcohol abuse within the last 5 years

• History of non-compliance to medical regimens and/or patients who are considered potentially unreliable

• Inability or unwillingness to give free informed consent