脳卒中予防と降圧治療の実際─ガイドラインと実際間のdiscrepancy─

抄録

Recommended measures for control of blood pressure in stroke patients at the superacute, acute and chronic stages were presented in two guidelines in 2004 (The Guideline for the Management of Hypertension and The Guideline for the Management of Stroke). We have investigated the discrepancy between actual clinical practice and the above recommendations.
We examined the clinical outcome and the incidence of symptomatic hemorrhage in patients with and without antihypertensive drug treatment before the administration of rt-PA in superacute stroke patients. We analyzed 47 patients with acute stroke treated within 3 hours after onset. According to the guideline, antihypertensive agents are indicated in patients with hypertension over 180mmHg systolic or 105mmHg diastolic pressure. Six patients showed the indication for antihypertensive therapy. There was no significant difference in prognosis measured in terms of mRS (0–1) at 3 months and the incidence of symptomatic hemorrhage between two groups. The recommended level of blood pressure in the guidelines is therefore considered appropriate for these patients.
Anti-hypertensive therapy in the acute phase within one or two weeks after onset has not been done in principle, except in special circumstances as described in the guidelines. We chose to examine the propriety of early anti-hypertensive therapy for patients with lacunar stroke, based on the tendency for shorter duration of hospitalization in acute hospitals, and because of the introduction of the seamless stroke collaboration system for treating stroke patients and the results of the ACCESS study, which showed that early intervention with ARB had a favorable effect on prognosis. We divided 100 patients with lacunar stroke into two groups according to the level of blood pressure. We prescribed anti-hypertensive agents (ARB or Ca channel blocker) in patients with over 180mmHg systolic or 105mmHg diastolic pressure within 2 weeks after onset. There was no significant difference in clinical outcome at 3 months or in the recurrence rate of stroke at one year between the two groups. The results suggested that early intervention with antihypertensive agents could be safe and appropriate in patients with lacunar stroke. However, this should be confirmed with more patients and a clinical trial.
As regards the goal for blood pressure in the chronic stage for the secondary prevention of stroke, the Japanese Guideline for Treatment of Hypertension recommended that the final goal should be under 140/90mmHg. Recent subanalysis of the PROGRESS study suggested that lowering the level to 120mmHg systolic pressure might be preferrable. However, Japanese and American Guidelines for Stroke Management have not given a precise goal for blood pressure, because of individual differences among patients. We think a new guideline recommending a lower level of blood pressure in certain kinds of stroke types and clinical situations is needed.