Research Article| Volume 26, ISSUE 2, P403-410, February 2017

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Higher Stroke Risk with Lower Blood Pressure in Hemodynamic Vertebrobasilar Disease: Analysis from the VERiTAS Study


      Despite concerns regarding hypoperfusion in patients with large-artery occlusive disease, strict blood pressure (BP) control has become adopted as a safe strategy for risk reduction of stroke. We examined the relationship between BP control, blood flow, and risk of subsequent stroke in the prospective Vertebrobasilar Flow Evaluation and Risk of Transient Ischemic Attack and Stroke (VERiTAS) study.


      The VERiTAS study enrolled patients with recent vertebrobasilar (VB) transient ischemic attack or stroke and ≥50% atherosclerotic stenosis or occlusion of vertebral or basilar arteries. Hemodynamic status was designated as low or normal based on quantitative magnetic resonance angiography. Patients underwent standard medical management and follow-up for primary outcome event of VB territory stroke. Mean BP during follow-up (<140/90 versus ≥140/90 mm Hg) and flow status were examined relative to subsequent stroke risk using Cox proportional hazards analysis.


      The 72 subjects had an average of 3.8 ± 1.2 BP recordings over 20 ± 8 months of follow-up; 39 (54%) had mean BP of<140/90 mm Hg. The BP groups were largely comparable for baseline demographics, risk factors, and stenosis severity. Comparing subgroups stratified by BP and hemodynamic status, we found that patients with both low flow and BP <140/90 mm Hg (n = 10) had the highest risk of subsequent stroke, with hazard ratio of 4.5 (confidence interval 1.3-16.0, P = .02), compared with the other subgroups combined.


      Among a subgroup of patients with VB disease and low flow, strict BP control (BP <140/90) may increase the risk of subsequent stroke.

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        • Kernan W.N.
        • Ovbiagele B.
        • Black H.R.
        • et al.
        Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
        Stroke. 2014; 45: 2160-2236
        • Meschia J.F.
        • Bushnell C.
        • Boden-Albala B.
        • et al.
        Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association.
        Stroke. 2014; 45: 3754-3832
        • Rothwell P.M.
        • Howard S.C.
        • Spence J.D.
        Relationship between blood pressure and stroke risk in patients with symptomatic carotid occlusive disease.
        Stroke. 2003; 34: 2583-2590
        • Turan T.N.
        • Cotsonis G.
        • Lynn M.J.
        • et al.
        Relationship between blood pressure and stroke recurrence in patients with intracranial arterial stenosis.
        Circulation. 2007; 115: 2969-2975
        • Powers W.J.
        • Clarke W.R.
        • Grubb Jr, R.L.
        • et al.
        Lower stroke risk with lower blood pressure in hemodynamic cerebral ischemia.
        Neurology. 2014; 82: 1027-1032
        • Amin-Hanjani S.
        • Rose-Finnell L.
        • Richardson D.
        • et al.
        Vertebrobasilar Flow Evaluation and Risk of Transient Ischaemic Attack and Stroke study (VERiTAS): rationale and design.
        Int J Stroke. 2010; 5: 499-505
        • Amin-Hanjani S.
        • Du X.
        • Rose-Finnell L.
        • et al.
        Hemodynamic features of symptomatic vertebrobasilar disease.
        Stroke. 2015; 46: 1850-1856
        • Amin-Hanjani S.
        • Pandey D.K.
        • Rose-Finnell L.
        • et al.
        Effect of hemodynamics on stroke risk in symptomatic atherosclerotic vertebrobasilar occlusive disease.
        JAMA Neurol. 2016; 73: 178-185
        • Amin-Hanjani S.
        • Du X.
        • Zhao M.
        • et al.
        Use of quantitative magnetic resonance angiography to stratify stroke risk in symptomatic vertebrobasilar disease.
        Stroke. 2005; 36: 1140-1145
        • Chobanian A.V.
        • Bakris G.L.
        • Black H.R.
        • et al.
        Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.
        Hypertension. 2003; 42: 1206-1252
        • Caplan L.R.
        • Wityk R.J.
        • Glass T.A.
        • et al.
        New England Medical Center Posterior Circulation registry.
        Ann Neurol. 2004; 56: 389-398
        • Arima H.
        • Chalmers J.
        • Woodward M.
        • et al.
        Lower target blood pressures are safe and effective for the prevention of recurrent stroke: the PROGRESS trial.
        J Hypertens. 2006; 24: 1201-1208
        • Wright Jr, J.T.
        • Williamson J.D.
        • Whelton P.K.
        • et al.
        A randomized trial of intensive versus standard blood-pressure control.
        N Engl J Med. 2015; 373: 2103-2116
        • Liebeskind D.S.
        • Cotsonis G.A.
        • Saver J.L.
        • et al.
        Collaterals dramatically alter stroke risk in intracranial atherosclerosis.
        Ann Neurol. 2011; 69: 963-974
        • Powers W.J.
        • Clarke W.R.
        • Grubb Jr, R.L.
        • et al.
        Extracranial-intracranial bypass surgery for stroke prevention in hemodynamic cerebral ischemia: the Carotid Occlusion Surgery Study randomized trial.
        JAMA. 2011; 306: 1983-1992
        • Muntner P.
        • Whittle J.
        • Lynch A.I.
        • et al.
        Visit-to-visit variability of blood pressure and coronary heart disease, stroke, heart failure, and mortality: a cohort study.
        Ann Intern Med. 2015; 163: 329-338