Hypertension is a well-established and modifiable risk factor for stroke and other cardiovascular diseases. Notably, stroke is the second leading cause of death worldwide and the second most common cause of disability-adjusted life-years. As such, we provide a viewpoint on blood pressure management in stroke and emphasize blood pressure control or management for first and recurrent stroke prevention, acute stroke treatment, and for prevention of cognitive impairment or dementia.

Background: Dual antiplatelet treatment (DAPT) with aspirin plus clopidogrel for a limited time is recommended after minor noncardioembolic stroke. Methods: We performed a meta-analysis of all major studies that compared the efficacy and safety of DAPT versus monotherapy for the secondary prevention of recurrent stroke or transient ischemic attack. The primary outcomes were stroke and the composite of stroke, transient ischemic attack, acute coronary syndrome, and death from any cause. The safety outcome was major hemorrhage. Relative risk (RR) and 95% CIs were calculated. Heterogeneity was assessed by I ² and Cochrane Q statistics. Results: The analysis included 27 358 patients, the quality of evidence was moderate to low, and the heterogeneity for all the comparisons was low ( I ² ≤25%). Compared with monotherapy, DAPT reduced the risk of recurrent stroke (RR, 0.71 [95% CI, 0.63–0.81]) and composite outcome (RR, 0.76 [95% CI, 0.69–0.83]) but increased the risk of major bleeding (RR, 2.17 [95% CI, 1.45–3.25]). In the subgroup analysis, ≤30 days of DAPT increased the risk of hemorrhage relative to monotherapy (RR, 1.94 [95% CI, 1.08–3.52]). In the sensitivity analysis, the risk for hemorrhage with ≤30 days of DAPT after excluding the combination of aspirin plus ticagrelor was comparable to monotherapy (RR, 1.42 [95% CI, 0.77–2.60]). However, the risk for stroke recurrence and composite outcomes in the subgroup and sensitivity analyses remain decreased compared with monotherapy. Conclusions: DAPT decreases the risk of recurrent stroke and composite events compared with monotherapy. DAPT increases the risk of major hemorrhage, except if the treatment is limited to 30 days and does not include the combination of aspirin plus ticagrelor.

Hypertension affects more than two-thirds of US adults 60 years or older,¹ and control is considered by some to be the “crown jewel” of stroke prevention. Despite mounting epidemiologic and mechanistic evidence linking raised blood pressure (BP) to cognitive decline or dementia, uncertainty remains about the benefit of lowering BP to prevent cognitive impairment.^2,3 Recent estimates suggest, for example, that 8% of cases of Alzheimer disease (AD) may be attributable to midlife hypertension, and the relative risk for midlife hypertension in AD is 1.6. Furthermore, multiple potential mechanisms link hypertension to cognitive compromise as we age.^4-6 Mechanistic endothelial dysfunction or vascular dysregulation, oxidative stress, and inflammation may interrupt vital homeostatic functions, resulting in structural brain and cognitive consequences.^5,6 Of further interest, epidemiologic evidence suggests a declining prevalence of dementia⁷ that may be explained at least in part by better control of cardiovascular risk factors over time. However, in a recently reported study among patients with type 2 diabetes mellitus, the Memory in Diabetes substudy of the Action to Control Cardiovascular Risk in Diabetes Trial (MIND ACCORD), intensive BP-lowering therapy (systolic BP [SBP], <120 mm Hg) plus fibrate therapy vs standard therapy (SBP, <140 mm Hg) in the presence of controlled low-density lipoprotein cholesterol levels did not result in a measurable effect on cognitive decline after 40 months of follow-up.⁸

• Brain health may be variably defined in broad or narrow terms. • Central to the definition of brain health is preservation of optimal brain structure and function. • Brain health may be influenced by 5 key determinants: physical health, the environment, physical safety and financial security, opportunities for social convergence, and access to health and social services. • Cognitive medicine may be defined as a discipline and research-focused area dealing with the study, identification, prevention, and treatment of cognitive impairment and decline.