Effects of Blood Pressure Lowering With Perindopril and Indapamide Therapy on Dementia and Cognitive Decline in Patients With Cerebrovascular Disease

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Abstract
IN 1990, dementia was the eighth leading cause of death and disability in higher-income countries,1 and by 2020, the disease burden attributable to dementia is projected to increase by one half.1 The identification of safe and effective interventions for the prevention of dementia is therefore a clinical and public health priority. Observational studies have demonstrated that elevated blood pressure levels2-5 and a history of cerebrovascular disease6-8 are each strongly associated with the long-term risks of dementia and cognitive impairment. Blood pressure–lowering interventions may reduce the risk of cognitive impairment by direct effects on the prevention of cerebrovascular disease or by indirect effects on the clinical expression of neurodegenerative processes.9-13 Three completed large-scale randomized controlled trials of blood pressure–lowering agents have reported the effects of treatment on the risk of dementia or measures of cognitive function.14-16 While the first identified no clear effect of study treatment on dementia14 and the second no effect on cognitive function,15 the third reported a significant beneficial effect of treatment on the risk of dementia.16 In that study, however, only 32 cases of dementia were recorded, and the confidence intervals about the estimate of treatment effect were very wide. There remains, therefore, substantial clinical uncertainty about the effects of blood pressure lowering on both dementia and other indexes of cognitive impairment.