Gina Kennedy - How intensively should we treat blood pressure in ...

PRESERVE: How to recruit successfully-Experience from NewcastleDr Gina Kennedy

• Who?• How?• Common exclusions• Frequently asked questions• Questions

Who?• Patients with moderate cerebral small vesseldisease, lacunar infarcts and hypertension• OR Memory Problems (vascular cognitiveimpairment)• Subjective complaint, objective deficit• MOCA 21• Radiological evidence

How?• Daily contact with wardscreeningnewadmissions• Attend clinics: TIA/ generalstroke/memory clinic• Database search (DNALacunar study,‘CaptureStroke’)• Research team/PIC sitetalks/visits• Screening flowchart onlocal network

Is blood pressure over 140 systolic?(currently no more than 2 antihypertensives)YesIs there less than 50% carotid/vertebral arterystenosis?YesHas the patient had a lacunar infarct in lastyear?YesHave they had an MRI scanin the last year?YesYesNoPatient suitable for MRIimaging?YesIs there moderate small vesseldisease and lacunar infarcts?NoIs there any indication of vascularcognitive impairment?(MOCA≤ 25/30)NoYes Not sure NoRefer to PRESERVE Team:0191 2820317Not suitable for PRESERVE

Patient 1• Patient 1: TIA on HASU,chronic hypertension,cerebral small vesseldisease• Previous lacunar infarctmore than 3 monthsago, already had MRIimaging in last yearwhich fulfilled criteria• Recruited immediatelyBaseline BP: 155/92

Patient 2• Identified as having hadlacunar infarct on strokedatabase more than ayear ago• Latest clinic visit:ongoing hypertension• MOCA 25/30• Entered on VCI armBaseline BP 171/99

Patient 3• Identified on strokedatabase as lacunar infarct• MRI compatible withrelevant acute lacunarinfarct at time of admission• ?borderline leukoaraiosis• ?White coat hypertension• Blood pressure variabilitymakes protocol BPtreatment difficult but stillvalidBaseline BP: 147/95

Patient 4• Met in the generalstroke clinic 6 monthsfollowing lacunar infarct• History of hypertension• Recurrent briefsymptoms, due forrepeat CTH, changed toMRI brain• Recruited immediately Baseline BP: 160/85

Patient 5• Met on ward followinglacunar infarct• Hypertensive• PRESERVE informationgiven to patient• MRI brain requested asOPD• Recruited 3/12 poststrokeBaseline BP: 140/73

Patient 6• Identified in strokeradiology meeting:moderate leukoaraiosis andold lacunar infarcts• No history or radiologicalevidence of recent lacunarinfarct• Admitted with an episodeof confusion ‘TGA’• Background mild memoryproblems• MOCA 24/30, MMSE 24/30• Recruited to VCI armBaseline BP: 154/79

Common Exclusions• Radiological criteria not met: Leukariosis

FAQ’s• Can patients withdiabetes be recruited?• In the standard arm(target 130-140 mmHg),should antihypertensivemedication bewithdrawn if bloodpressure

Blood Pressure TargetsBP (mmhg)200180185171168160164155155157149140143120125116119100 9910092928484 868078 808070706040200 1Basline 2 week 1 month 6 week 2 month 3 monthTIME

•Acknowledgements• Professor Gary Ford and thestroke team at RVI• All the stroke specialist nurses• Ahmed Barkat (Clinical TrialsOfficer)• John Davis (Senior ResearchNurse)• Teresa Thompson (Data Manager)• Michelle Fawcett (ResearchNurse)• Valerie Hodge (Research Nurse)