PROGRESS (perindopril protection against recurrent stroke study)

The peridopril protection against recurrent stroke study (PROGRESS) investigated the efficacy of blood-pressure reduction in hyper- and normotensive patients with a history of stroke or TIA (1).

Recurrent stroke was reduced in patients randomised to anti-hypertensive treatment.

The study authors suggest that perindopril and indapamide therapy should be considered routinely for patients with a history of stroke or TIA - however the routine use of perindopril and indapamide following a stroke been questioned by some (2).

Summary points (2):

• the PROGRESS trial reports that a "perindopril-based blood-pressure-lowering regimen" provided significant protection against recurrent stroke
  • however only the subgroup receiving both perindopril and indapamide had reduced stroke recurrence
    • there was significant difference in blood pressure reduction achieved with the combination of indapamide and perindopril versus perindopril alone
      • blood pressure differences between the two arms (5/3 mm Hg for perindopril alone v 12/5 mm Hg for the combined therapy) - this may have had a significant effect on risk of stroke rather than an effect of the ACE inhibitor independent of blood pressure reduction
  • the study design did not include a subgroup randomised to indapamide alone (previously shown to reduce stroke recurrence) - which thus did not allow assessment of the effect of indapamide alone on reduction of stroke risk
• some reviews of the PROGRESS trial have advocated using perindopril alone for prevention of stroke recurrence - however this does not follow from the findings
• it is important that "..results from major drug trials must be clearly presented to avoid misinterpretation by busy clinicians." (1)

Reference:

• (1) PROGRESS Collaborative Group. Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6105 individuals with previous stroke or transient ischaemic attack. Lancet 2001; 358: 1033-41.
• (2) Wennberg R, Zimmermann C.The PROGRESS trial three years later: time for a balanced of effectiveness.BMJ. 2004 Oct 23;329(7472):968-70.