Hypertension and stroke.

The longitudinal analysis of the adult population of Framingham, Massachusetts has clarified the pivotal role of hypertension in the epidemiology of stroke. Stroke incidence increases in men and women as arterial blood pressure, either systolic or diastolic, increases. Isolated systolic hypertension increases the risk of stroke in the elderly. Successful antihypertensive therapy decreases stroke incidence in asymptomatic persons, hypertensive patients with transient ischemic attacks and survivors of hypertensive stroke. A stepped care approach to antihypertensive therapy utilizing diuretic drugs, antiadrenergic agents and vasodilators is well tolerated in the vast majority of patients with established cerebrovascular disease. Agents with a propensity to cause orthostatic hypotension should be avoided. Reduction of blood pressure should be gradual with dose increments at intervals of 6 to 8 weeks. Mild hypertension may be left untreated during the acute phase of atherothrombotic brain infarction. A trial of blood pressure reduction with sodium nitroprusside to normotensive or mildly hypotensive levels is indicated in patients with acute intracranial hemorrhage. If neurologic deterioration occurs, the infusion rate of sodium nitroprusside can be reduced and blood pressure will rapidly rise. Successful management of hypertension has undoubtedly contributed to the decreasing death rate from stroke in the United States.