Angiotensin-converting enzyme inhibitor decreases cerebral small vessel disease risk: AHA

USA: A new study conducted by Eric D. Goldstein and the team showed that angiotensin-converting enzyme inhibitor was most consistently linked to decreased white matter hyperintensities (WMH) advancement among SPRINT-MIND study participants irrespective of blood pressure management. The findings of this study were published in the Stroke journal.

The risk of cerebral small vessel disease (CSVD) progression is decreased by the treatment of uncontrolled arterial hypertension, but it is unclear whether this reduction results from blood pressure control or class-specific pleiotropic effects, such as increased beat-to-beat arterial pressure variability with calcium channel blockers. In order to better understand how antihypertensive medications, particularly calcium channel blockers, affect the formation of white matter hyperintensities, a radiographic marker of CSVD, in a cohort of people with well-controlled hypertension, this study was done.

The SPRINT-MIND trial (Systolic Blood Pressure Trial Memory and Cognition in Decreased Hypertension), a significant randomized controlled trial with participants who underwent baseline and 4-year follow-up brain MRI with volumetric WMH data, underwent observational cohort analysis. At follow-up appointments in between the magnetic resonance imaging, information regarding antihypertensive medication was logged. The percentage of individuals who were prescribed each of the 11 classes of anti-hypertensives throughout the follow-up period was then calculated. A top tertile of the distribution was dichotomized in order to address skew when calculating the progression of CSVD as the difference in WMH volume between two scans.

The key highlights of this study were:

1. With the exception of age and systolic blood pressure, the vascular risk profiles among the 448 participants were comparable among WMH progression subgroups.

2. The intense blood pressure arm included 72 (48.3%) of the top tertile cohort and 177 (59.2%) of the remaining cohort.

3. The mean WMH progression for those in the top tertile was 4.7±4.3 mL as opposed to 0.13±1.0 mL.

4. Dihydropyridine calcium channel blockers lost significance when WMH was considered as a continuous variable, while the use of ACE inhibitors and calcium channel blockers was linked with decreased WMH advancement.

Intriguingly, the only two medication classes that were linked to slower development of cerebral small artery disease in cohorts of individuals with hypertension were ACE inhibitor (and maybe ARB) and D-CCB classes. More research is required to provide more light on how different antihypertensive classes affect the burden of cerebrovascular disease differently.

Reference: 

Goldstein, E. D., Wolcott, Z., Garg, G., Navarro, K., Delic, A., Yaghi, S., Sederholm, B., Prabhakaran, S., Wong, K.-H., McLean, K., & de Havenon, A. H. (2022). Effect of Antihypertensives by Class on Cerebral Small Vessel Disease: A Post Hoc Analysis of SPRINT-MIND. In Stroke (Vol. 53, Issue 8, pp. 2435–2440). Ovid Technologies (Wolters Kluwer Health). https://doi.org/10.1161/strokeaha.121.037997