Missed Opportunities for Stroke Prevention in Patients With Hypertension: A Retrospective Case–Control Study

BACKGROUND: Hypertension is the leading modifiable risk factor for ischemic stroke, yet the adequacy of preventative hypertension care in routine clinical practice remains suboptimal, potentially representing missed opportunities for stroke prevention. We evaluated the association between hypertension care delivery and incident ischemic stroke. METHODS: We conducted a retrospective, matched, nested case-control study among adults with hypertension using data from a large regional health system (2010-2024). Patients with a first-ever ischemic stroke were matched 1:2 to controls on age, sex, race and ethnicity, and calendar time. Three care metrics were assessed: (1) outpatient visits with blood pressure measurement per year; (2) number of antihypertensive medication ingredients; and (3) medication intensification score. Conditional logistic regression estimated adjusted odds ratios. RESULTS: The study included 13 476 cases and 26 952 matched controls. Cases had fewer blood pressure visits per year (median, 2.50 versus 3.01), similar number of medication ingredients (2.00 versus 2.00), and lower treatment intensification scores (-0.211 versus -0.125). Compared with ≤1 visit, >5 blood pressure visits per year was associated with lower stroke odds (adjusted odds ratio, 0.55 [95% CI, 0.51-0.59]). Use of 2 to 3 medication ingredients (versus 0) was also associated with reduced stroke odds (adjusted odds ratio, 0.80 [95% CI, 0.75-0.86]), whereas >3 ingredients was not. The highest quartile of treatment intensification showed the strongest association (adjusted odds ratio, 0.47 [95% CI, 0.44-0.51]). Findings were consistent across subgroup and sensitivity analyses. CONCLUSIONS: Greater engagement in hypertension care was associated with lower odds of ischemic stroke, suggesting that gaps in routine management may represent missed opportunities for prevention.