Enalapril-folic acid therapy significantly cut cardiovascular risk and recurrent stroke in H-type hypertensive patients.
Background
Individuals with hemorrhagic stroke and H-type hypertension (elevated homocysteine) face a heightened risk of recurrent stroke and other cardiovascular events. Current standard-of-care often focuses on blood pressure control, but the specific role of homocysteine-lowering strategies in secondary prevention for this high-risk group remains a critical gap. Folic acid, known to reduce homocysteine levels, combined with an ACE inhibitor like enalapril, offers a potential synergistic approach to mitigate these risks, warranting investigation into its real-world impact on clinical outcomes.
Study Design
This prospective study enrolled 799 patients with hemorrhagic stroke and H-type hypertension (total homocysteine levels ≥ 10 μmol/L). Participants received a daily regimen of enalapril (10 mg) and folic acid (0.8 mg). They were monitored for a median duration of 9.6 months. Adherence was categorized as high (≥ 70%) or low (< 70%). The primary endpoint was a composite of CVD events (cardiovascular mortality, nonfatal myocardial infarction, nonfatal stroke). Cox proportional hazards models were used to analyze the relationship between adherence and outcomes, adjusting for confounders.
Results
During the follow-up period, 40 participants (5.0%) developed CVD, and 21 participants (2.6%) experienced recurrent hemorrhagic stroke. Patients demonstrating high adherence to enalapril-folic acid therapy showed significantly reduced risks across multiple endpoints.
Patients with high adherence to enalapril-folic acid therapy exhibited significantly reduced risks of CVD (hazard ratio [HR]: 0.16; 95% CI: 0.06-0.45), recurrent hemorrhagic stroke (HR: 0.21; 95% CI: 0.07-0.67), and all-cause mortality (HR: 0.14; 95% CI: 0.05-0.41) when compared to those with low adherence. This translates to an 84% reduction in CVD risk, a 79% reduction in recurrent hemorrhagic stroke, and an 86% reduction in all-cause mortality for highly adherent individuals. Subgroup analyses consistently supported these findings across various stratifications including sex, age, BMI, blood pressure, total cholesterol, and total homocysteine levels.
Key Findings
- High adherence to enalapril-folic acid therapy reduced CVD risk by 84% (HR: 0.16; 95% CI: 0.06-0.45).
- Recurrent hemorrhagic stroke risk was cut by 79% (HR: 0.21; 95% CI: 0.07-0.67) with high adherence.
- All-cause mortality decreased by 86% (HR: 0.14; 95% CI: 0.05-0.41) in highly adherent patients.
- During follow-up, 5.0% of participants developed CVD and 2.6% experienced recurrent hemorrhagic stroke.
Why It Matters
This study provides compelling evidence that high adherence to enalapril-folic acid therapy significantly improves outcomes for individuals with hemorrhagic stroke and H-type hypertension. For clinicians and individuals managing these conditions, this suggests that emphasizing and supporting adherence to this dual therapy could be a critical, accessible strategy for secondary stroke prevention and overall cardiovascular risk reduction. The specific daily doses of enalapril (10 mg) and folic acid (0.8 mg) are clearly defined, offering a practical protocol. While further randomized controlled trials are needed, these prospective findings highlight the potential for a simple, cost-effective intervention to substantially impact patient prognosis.
folic-acid
enalapril
hemorrhagic-stroke
hypertension
cardiovascular-disease
homocysteine