More intensive treatment to lower systolic blood pressure in middle-aged adults who have already had an ischaemic stroke or transient ischaemic attack (TIA) can significantly reduce the risk of future strokes, heart attacks, and other major cardiovascular events, according to new, independent, preliminary late-breaking science presented at the 2026 American Heart Association (AHA) Scientific Sessions (7–9 November, Chicago, USA). These findings from the OPTIMAL-STROKE study have also been published in the New England Journal of Medicine.
“Controlling blood pressure after a stroke is especially important because it can help prevent another stroke, prevent other cardiovascular complications, and protect patients’ lives,” said Otavio Berwanger (Imperial College London, London, UK), chair of the OPTIMAL-STROKE study steering committee, and the study’s senior author.
“Our study shows that, for many people who have already experienced an ischaemic stroke or TIA, aiming for a systolic blood pressure below 120mmHg can provide additional cardiovascular protection compared with the conventional target of below 140mmHg. However, we emphasise that achieving lower blood pressure safely requires appropriate medical supervision and additional monitoring, particularly of kidney function,” added Gisele Sampaio (Albert Einstein Hospital, São Paulo, Brazil), the study’s principal investigator.
In a press release, the American Heart Association (AHA) notes that its 2025 guideline on the prevention, detection, evaluation and management of high blood pressure in adults—published jointly with the American College of Cardiology (ACC)—recommends maintaining systolic blood pressure at less than 130mmHg and diastolic blood pressure at less than 80mmHg, and encourages blood pressure measures of less than 120mmHg for people at increased risk for cardiovascular disease.
The present study—the OPTIMAL-STROKE trial—investigated the optimal blood pressure target to prevent a recurrent stroke. The trial was conducted at 30 health centres in Brazil, with 4,368 patients (average age, 64 years; 47.9% women) enrolled between 2019 and 2022. It evaluated the impact of intensive antihypertensive treatment on the incidence of cardiovascular death, heart attack, stroke, and other major cardiovascular events including hospitalisation for unstable angina or heart failure. Study participants had previously experienced an ischaemic stroke or TIA, and had elevated blood pressure between 130–180mmHg.
During the four-year intervention, participants in the intensive blood pressure-lowering group were found to be roughly 21% less likely to experience a major cardiovascular event than participants in the standard treatment group. Cardiovascular events occurred in 236 participants (10.9%) on intensive therapy and in 297 participants (13.5%) on standard therapy.
Furthermore, participants in the intensive therapy group had a lower rate of recurrent strokes when compared to those in the standard treatment group, as per rates of 4.7% and 6.4%, respectively. This difference was driven by fewer ischaemic strokes in the intensive therapy group, according to the study investigators.
While serious adverse events were similar in both groups, the investigators believe an increase in kidney-related events in the intensive treatment group highlights the importance of individualised treatment and careful monitoring.
“High blood pressure is the single most important modifiable risk factor for stroke, and controlling blood pressure is essential to prevent another stroke,” Sampaio commented. “For stroke survivors, it’s important to take three steps: know your blood pressure, take your prescribed medications consistently, and discuss your individual blood pressure target with your healthcare team. A lower blood pressure target may offer greater protection, and we must ensure that the right target is achieved safely and tailored to each patient.”
The researchers also highlight one important limitation of this study: not all patients in the intensive therapy group achieved the target of systolic blood pressure below 120mmHg. Additionally, these results may not be generalisable to people living outside of Brazil, where healthcare access and options, and environmental factors, differ from other geographies.
