White matter lesions-should all patients receive antihypertensive treatment?

Christopher Chen, BA, BMBCh, MRCP, FAMS, FRCPE, National University of Singapore, Singapore, discusses the role played by hypertension in the risk of developing white matter (WM) lesions, and how blood pressure-lowering agents may help reduce WM lesion load. WM lesions are particularly prevalent in the elderly and are typically considered a marker of small vessel disease, although can also be associated with degenerative or inflammatory processes. Due to the risk of recurrent stroke events, dementia and death, Prof. Chen stresses the importance of addressing WM lesions with antihypertensive treatment. Epidemiological and clinical studies have both demonstrated that WM lesion burden can be reduced with blood pressure treatment. In the recent two-arm, randomized SPRINT trial (NCT01206062) cognitive benefits as well as improved cardiovascular outcomes were achieved by lowering systolic blood pressure targets from 140 to 120 mmHg. A small MRI sub-study suggested these cognitive benefits may be attributable to a reduction in WM burden. Several trials are ongoing which may provide more definitive answers on which patients should be treated and to what extent. This interview took place at the European Stroke Organisation Conference (ESOC), 2021.