How intensively should we treat blood pressure in established cerebral small vessel disease?

 

Cerebral small vessel disease (SVD) accounts for about 20 per cent of all stroke and is the major cause of vascular cognitive impairment and dementia. The major risk factor is hypertension but in patients with severe disease (with radiological changes of extensive white matter damage or leukoaraiosis) we do not know how intensively we should treat blood pressure.

In this clinical trial we will determine whether intensive, versus standard, treatment of blood pressure in hypertensive individuals with SVD and radiological leukoaraiosis is associated with reduced cognitive decline. In nested substudies we will investigate the underlying mechanism and determine whether any treatment effect is mediated through a reduced rate of white matter damage assessed by Diffusion Tensor MRI, and/or through an increase in cerebral blood flow assessed using arterial spin labelling MRI. In addition to answering this important clinical question we will use the MRI substudy data to compare the sensitivity of DTI MRI and brain atrophy as markers of white matter damage for therapeutic trials, compared with the conventional MRI marker of T2 white matter lesion volume, and assess their relationship to cognitive decline. This will provide novel and important data on the use of surrogate MRI markers for future clinical trials.