Please select the eligibility criteria that correspond to the clinical trial below.
Title: A Randomized Controlled Trial to Assess the Effect of Intensive Blood Pressure Control on Major Cardiovascular Events in Stroke Patients
Brief Summary: Elevated blood pressure (BP) consists of a major public health concern especially in low and middle income countries. Besides being a highly prevalent condition, it is also a risk factor for several major cardiovascular events including stroke (which consists of the second leading cause of death in developing countries) and coronary artery disease, and is also related to cognitive decline. The OPTIMAL Stroke trial consists of a two-arm, multicenter, randomized clinical trial designed to test whether a lower target systolic blood pressure (SBP) as compared to the currently recommended target for stroke patients will reduce the occurrence of major cardiovascular events.


Options:
A: Inclusion Criteria:

* Documented systolic blood pressure greater than or equal to 130 mmHg
* Undergoing planned catheter ablation for persistent AF (lasting \> 7 days and \< 365 days or requiring electrical or chemical cardioversion) OR High burden paroxysmal AF \> 6 months (greater than or equal to 3 symptomatic episdes in past 6 months and refractory or inteolerant to at least 1 class 1 or 3 antiarrhythmic)

Exclusion Criteria:

* Permanent atrial fibrillation
* Contraindication to Accupril or any other ACE-I
* Women of child-bearing potential
* Life expectancy less than 1 year
* Less than 18 years of age
* Unable to give informed consent
* Known moderate to several renal dysfunction (eGFR \< 30 ml/min/1.73m2)
* Prior AF catheter ablation
B: Inclusion Criteria:

* Men and women aged ≥40 years
* A history of symptomatic, MRI/CT-confirmed ischemic stroke (3-12 months since last acute onset)
* Systolic BP ≥140 mmHg on 0 medication; 135-180 mmHg on 1 medication; 135-170 mmHg on up to 2 medications; 135-160 mmHg on up to 3 medications; or 135-150 mmHg on up to 4 medications

Exclusion Criteria:

* Documented symptomatic intracranial and/or extracranial stenosis (≥50%), or asymptomatic intracranial and/or extracranial stenosis (≥70%)
* Disabling stroke (modified Rankin score of ≥4)
* Previous intracranial hemorrhage from a non-traumatic cause
* Any symptoms of orthostatic hypotension during the standing BP measurement, or standing systolic BP \<110 mmHg
* Severe heart failure (NY Heart Association class III and IV) within the past six months or left ventricular ejection fraction (by any method) \<35%
* Any history of atrial fibrillation, ventricular aneurysm, or suspicion of cardioembolic pathology for stroke
* Other specific cause of stroke identified by routine clinical care (e.g., arteritis, dissection, migraine/vasospasm, drug abuse)
* Dialysis, eGFR \<20 ml/min/1.73 m2, urine protein-to-creatinine ratio ≥1 g/g, or albumin-to-creatinine ratio ≥ 600 mg/g
* Planned or probable revascularization (any angioplasty or vascular surgery) within three months after screening
* A medical condition likely to limit survival to less than three years
* A cancer diagnosed and treated within the past two years that, in the judgment of clinical study staff, would compromise a participant's ability to comply with the protocol and complete the trial (except non-melanoma skin cancer, early-stage prostate cancer, or localized breast cancer)
* Any factors judged by the clinic team to be likely to limit adherence to the intervention
* Failure to obtain informed consent from a participant
* Currently participating in another intervention study
* Pregnant, currently trying to become pregnant, or of child-bearing potential and not using birth control
C: INCLUSION:

Small subcortical ischemic stroke or subcortical TIA.

Inclusion criteria are based on TOAST criteria supplemented by required MRI data. All of the following criteria must be met:

* One of the lacunar stroke clinical syndromes (adapted from Fisher) lasting \> 24 hrs within the past 6 months
* Absence of signs or symptoms of cortical dysfunction such as aphasia, apraxia, agnosia, agraphia, homonymous visual field defect, etc.
* No ipsilateral cervical carotid stenosis (≥50%) by a reliable imaging modality done in an approved laboratory since the qualifying small subcortical stroke (S3), if hemispheric.
* No major-risk cardioembolic sources requiring anticoagulation or other specific therapy. Minor-risk cardioembolic sources will be permitted if anticoagulation is not prescribed by the patient's primary care physician.
* Subcortical TIA with corresponding lesion on DWI.
* MRI evidence of S3: a. Presence of an S3 (1.5 and 2 cm in diameter corresponding to the qualifying event on DWI; when TIA, ADC image must confirm lesion or T2/FLAIR (hyperintense lesions) (required for all brainstem events) OR multiple S3s on FLAIR/TI(\<1.5 cm in diameter) (hypointense lesions) b. Absence of cortical stroke and large subcortical stroke (recent or remote).

EXCLUSION:

To be eligible for entry into the study, the patient must not meet any of the criteria listed below:

* Disabling stroke (Modified Rankin Scale less than or equal to 4)
* Previous intracranial hemorrhage (excluding traumatic) or hemorrhagic stroke
* Age under 30 years
* High risk of bleeding (e.g. recurrent GI or GU bleeding, active peptic ulcer disease, etc)
* Anticipated requirement for long-term use of anticoagulants (e.g. recurrent DVT) or other antiplatelets
* Prior cortical stroke (diagnosed either clinically or by neuroimaging), or prior cortical or retinal TIA
* Prior ipsilateral carotid endarterectomy
* Impaired renal function: GFR \<40
* Intolerance or contraindications to aspirin or clopidogrel (including thrombocytopenia, prolonged INR)
* A score \< 24 (adjusted for age and education) on the Folstein Mini Mental Status Examination
* Medical contraindication to MRI
* Pregnancy or women of child-bearing potential who are not following an effective method of contraception
* Geographic or social factors making study participation impractical
* Unable or unwilling to provide informed consent
* Unlikely to be compliant with therapy/unwilling to return for frequent clinic visits
* Patients concurrently participating in another study with an investigational drug or device
* Other likely specific cause of stroke (e.g. dissection, vasculitis, prothrombotic diathesis, drug abuse)
D: Inclusion Criteria:

* History of ischemic stroke or transient ischemic attack (TIA), considered clinically stable in the 48 hours prior to inclusion in the study. (they will be classified into a recent stroke \<120 days or chronic when\> 120 days), AND
* Systolic Blood Pressure (SBP) between 130 and 180 mmHg:

  * 130 -180 and use of up to one antihypertensive drug;
  * 130-170 and use of up to two drugs;
  * 130-160 and use of up to three drugs;
  * 130-150 and use of up to four drugs. AND

Exclusion Criteria:

* Severe disability after the event that qualified the patient for the study, defined as a modified Rankin (mRankin) scale equal to or greater than 4.
* Being part of another clinical trial involving interventions for cardiovascular prevention.
* Body mass index \> 45 kg/m2.
* Pregnancy or Breastfeeding.
* Secondary hypertension.
* Class IV Canadian Cardiovascular Society (CCS) Resting Angina.
* Acute coronary syndrome in the last six months
* Severe renal dysfunction with GFR \< 20 mL/min/1.73m2 calculated by the CKD-EPI equation
* Refusal to consent.
* Symptomatic heart failure - Class IV New York Heart Association (NYHA) or ejection fraction \<35% on Doppler echocardiography.
* Conditions that, at the investigators' discretion, limit the patient's participation in the study, including but not limited to the following:

  * Recent history of alcohol and illicit drug abuse.
  * Psychiatric comorbidities (severe depression, schizophrenia, psychosis, etc.).
  * History of poor drug adherence and no attendance at consultations.
  * Planning to change of address in the next four years.
  * Planning to be absent from home city for more than three months in the next year.
  * Residing in the same residence of another patient previously included in this study.

Answer: D