By Matthew E. Fink, MD

Louis and Gertrude Feil Professor and Chair, Department of Neurology; Associate Dean for Clinical Affairs, NewYork Presbyterian/Weill Cornell Medical College

SOURCE: Markus HS, Egle M, Croall ID, et al. PRESERVE: Randomized trial of intensive versus standard blood pressure control in small vessel disease. Stroke 2021;52:2484-2493.

Small vessel disease of the brain accounts for 20% to 25% of all ischemic strokes and is a common cause of vascular cognitive impairments. The major risk factor for small vessel disease is hypertension. The precise target blood pressure that is optimal to prevent stroke or long-term cognitive impairment in these patients is undetermined. To prevent other cardiovascular events, researchers have recommended targeting a systolic blood pressure of 120 mmHg to 125 mmHg, but this has not been confirmed as effective in preventing stroke or long-term cognitive impairment. Because cerebral autoregulation is impaired in these patients, lowering the blood pressure too much runs the risk of accelerating white matter damage and making outcomes worse. Markus et al performed a randomized, multicenter, controlled, and blinded-to-outcomes clinical trial with 111 patients who had MRI-confirmed symptomatic lacunar infarcts and extensive white matter hyperintensities. They were randomized into one of two groups: targeting a systolic blood pressure of 130 mmHg to 140 mmHg or intensive blood pressure lowering, targeting systolic blood pressure of < 125 mmHg. The primary endpoint was a change in diffusion tensor imaging of white matter mean diffusivity between baseline evaluation and 24 months of treatment. Secondary endpoints were imaging markers of recurrent stroke, progression of white matter abnormalities, and cognitive impairments. The mean age of the patients was 60 years, and 60% were men. The mean blood pressure reduction was 15.3 mmHg and 23.1 mmHg in the standard and intensive groups, respectively (P < 0.001). There was no difference between the treatment groups in the primary endpoint, and no significant difference between white matter hyperintensities or a decrease in cognition over the 24 months of follow-up. The investigators concluded intensive blood pressure lowering was not associated with worsening but did not demonstrate any benefit in this population over standard blood pressure management.