The commonest failure in secondary stroke prevention is not choosing the wrong antihypertensive. It is that nobody wrote down what the pressure should be, so the general practitioner continuing the prescription has no way to know whether the patient is at target or 20 mmHg above it.
A discharge summary that says 'amlodipine 5 mg' transmits a drug. A summary that says 'amlodipine 5 mg, target systolic below 130, titrate at 4-week intervals, recheck in 6 weeks' transmits a plan. The second version is what actually gets a patient to target, because the person doing the titrating is usually not the person who set the target.
Three things belong in that sentence: the number, the interval at which to escalate, and who is responsible for the next review. Add the reason where it is not obvious — 'after intracerebral haemorrhage' changes how hard a general practitioner will push, because the indication is stronger than for primary prevention.
The same applies to the patient's own copy. A survivor who knows their target number will check it; one who has only been told to take a tablet will not. Where home monitoring is affordable, a written target turns the machine from a source of anxiety into a tool.
One caution: set a target that accounts for postural symptoms and falls risk. An intensive target the patient cannot tolerate produces a patient who stops the drug entirely, which is worse than a modest target achieved.
- Write the target systolic number in the discharge summary, not just the drug and dose
- State the titration interval and who reviews next — the person titrating is rarely the person who set the target
- Give the indication explicitly; 'after intracerebral haemorrhage' justifies a firmer target than primary prevention
- Give the patient their own target number, especially where home monitoring is available
- Check standing blood pressure and ask about dizziness before setting an intensive target in an older patient
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