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Journal Club

Journal Club. Jim Hoehns, Pharm.D . Lancet 2013;382:507-15. Stroke Subtypes and Incidence. Hemorrhagic stroke 15%. Other 5% . Cryptogenic 30%. Atherosclerotic cerebrovascular disease 20%. Small vessel disease “ lacunes ” 25%. Cardiogenic embolism 20%.

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Journal Club

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  1. Journal Club Jim Hoehns, Pharm.D.

  2. Lancet 2013;382:507-15

  3. Stroke Subtypes and Incidence Hemorrhagicstroke15% Other5% Cryptogenic30% Atherosclerotic cerebrovascular disease 20% Small vessel disease “lacunes” 25% Cardiogenicembolism20% Ischemicstroke85% Albers G et al. Chest. 2001; 119 (suppl): 300S.

  4. SPS 3 Trial – Blood Pressure Targets • Randomized, open-label, multi-center trial • 3,020 patients; mean follow-up: 3.4 years • North America, Latin America, Spain; 81 centers • Funding: NINDS • Treatment • High SBP: 130-149 mm Hg • Low SBP: <130 mm Hg • Randomization • Stratified by baseline hypertensive status • Inclusion criteria: • Age ≥30 yrs • Symptomatic lacunar stroke within past 180 days • MRI criteria: lesion ≤ 2.0 cm; corresponded to clinical syndrome • TIAs allowed only if MRI evidence present • No surgically correctable carotid artery disease • No major risk factors for cardioembolic stroke Starting at least 2 weeks after stroke N Engl J Med 2012;367:817-25.

  5. SPS 3 Trial – Blood Pressure Targets • Exclusion criteria: • History of intracerebral bleeding • Disabling stroke (modified Rankin score ≥4) • Primary outcome: • Stroke recurrence (any ischemic stroke or ICH, including subdural hematomas) • Power analysis: • Estimated 3 yr rate of recurrent stroke: 21% • 90% power to detect 25% RRR with combination • Blood pressure • Managed by site PI

  6. Median time from qualifying stroke until randomization: 62 days

  7. 138 127 At 1 year: 75% of high BP group at goal, 65% of low BP group at goal

  8. Limitations • Rate of recurrent stroke much lower than anticipated • Frequent use of statins, high adherence to antiplatelets, good BP control in both groups • Unblinded; however endpoints were adjudicated in blind fashion • Approximately 5% in either group did not attain BP goal

  9. Summary • Authors • Findings consistent with those of previous studies…support a treatment target of <130 for most patients with recent lacunar stroke • Intervention well tolerated • BP meds permanently discontinued in 17% in both groups • Patient disposition • 3% lost to follow-up • 15% prematurely discontinued study

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