Intensive versus guideline blood pressure and lipid lowering in patients with previous stroke: main results from the pilot ‘Prevention of decline in cognition after stroke trial’ (PODCAST) randomised controlled trial

Bath, Philip M.W.; Scutt, Polly; Blackburn, Daniel J.; Ankolekar, Sandeep; Krishnan, Kailash; Ballard, Clive; Burns, Alistair; Mant, Jonathan; Passmore, Peter; Pocock, Stuart; Reckless, John; Sprigg, Nikola; Stewart, Rob; Wardlaw, Joanna M.; Ford, Gary A.

Abstract

Background

Stroke is associated with the development of cognitive impairment and dementia. We assessed the effect of intensive blood pressure (BP) and/or lipid lowering on cognitive outcomes in patients with recent stroke in a pilot trial.

Methods

In a multicentre, partial-factorial trial, patients with recent stroke, absence of dementia, and systolic BP (SBP) 125–170 mmHg were assigned randomly to at least 6 months of intensive (target SBP <125 mmHg) or guideline (target SBP <140 mmHg) BP lowering. The subset of patients with ischaemic stroke and total cholesterol 3.0–8.0 mmol/l were also assigned randomly to intensive (target LDL-cholesterol <1.3 mmol/l) or guideline (target LDL-c <3.0 mmol/l) lipid lowering. The primary outcome was the Addenbrooke’s Cognitive Examination-Revised (ACE-R).

Results

We enrolled 83 patients, mean age 74.0 (6.8) years, and median 4.5 months after stroke. The median follow-up was 24 months (range 1–48). Mean BP was significantly reduced with intensive compared to guideline treatment (difference –10·6/–5·5 mmHg; p<0·01), as was total/LDL-cholesterol with intensive lipid lowering compared to guideline (difference –0·54/–0·44 mmol/l; p<0·01). The ACE-R score during treatment did not differ for either treatment comparison; mean difference for BP lowering -3.6 (95% CI -9.7 to 2.4), and lipid lowering 4.4 (95% CI -2.1 to 10.9). However, intensive lipid lowering therapy was significantly associated with improved scores for ACE-R at 6 months, trail making A, modified Rankin Scale and Euro-Qol Visual Analogue Scale. There was no difference in rates of dementia or serious adverse events for either comparison.

Conclusion

In patients with recent stroke and normal cognition, intensive BP and lipid lowering were feasible and safe, but did not alter cognition over two years. The association between intensive lipid lowering and improved scores for some secondary outcomes suggests further trials are warranted.

Citation

Bath, P. M., Scutt, P., Blackburn, D. J., Ankolekar, S., Krishnan, K., Ballard, C., Burns, A., Mant, J., Passmore, P., Pocock, S., Reckless, J., Sprigg, N., Stewart, R., Wardlaw, J. M., & Ford, G. A. (2017). Intensive versus guideline blood pressure and lipid lowering in patients with previous stroke: main results from the pilot ‘Prevention of decline in cognition after stroke trial’ (PODCAST) randomised controlled trial. PLoS ONE, 12(1), Article e0164608. https://doi.org/10.1371/journal.pone.0164608

• Journal Article Type: Article
• Acceptance Date: Sep 28, 2016
• Publication Date: Jan 17, 2017
• Deposit Date: Aug 15, 2017
• Publicly Available Date: Aug 15, 2017
• Journal: PLOS ONE
• Electronic ISSN: 1932-6203
• Publisher: Public Library of Science
• Peer Reviewed: Peer Reviewed
• Volume: 12
• Issue: 1
• Article Number: e0164608
• DOI: https://doi.org/10.1371/journal.pone.0164608
• Public URL: https://nottingham-repository.worktribe.com/output/840011
• Publisher URL: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0164608
• Contract Date: Aug 15, 2017