Intensive, long-term blood pressure (BP)-lowering treatment reduces the risk of recurrent stroke by 38%—without increasing serious adverse events—in people who have survived an intracranial haemorrhage (ICH), as per the findings of a major meta-analysis published today in The Lancet Neurology.
Researchers analysed data from four randomised controlled trials involving 2,944 adults with ICH. Two studies investigated fixed-dose antihypertensive therapies and two evaluated treatment strategies based on defined BP targets. TRIDENT was the only trial in this analysis that exclusively enrolled patients with spontaneous ICH, while the remaining trials included people with either ischaemic stroke or ICH at baseline.
During a follow-up period of up to six years, recurrent stroke of any type occurred in 6.5% of patients receiving intensive BP lowering compared with 10.4% of those receiving less intensive treatment or standard care in the control arm. This translated to a 38% reduction in recurrent stroke risk, with consistent benefits observed across all studies.
According to senior author Craig Anderson (The George Institute, Sydney, Australia), these findings provide compelling evidence for more intensive BP management after ICH.
“ICH is one of the deadliest forms of stroke, with limited treatment options and a high risk of recurrence among survivors,” Anderson commented. “Our analysis shows that intensive BP treatment can prevent 16 recurrent strokes for every 1,000 patients treated within the first year alone. These findings reinforce the central role of BP control in secondary stroke prevention.”
During follow-up, the average systolic BP was 127mmHg in the intensive treatment group and 138mmHg in the control group, representing a mean difference of 11.2mmHg.
The reduction in recurrent stroke was mainly driven by an approximately 61% lower risk of ICH among patients receiving intensive treatment. Additionally, there was no observed increase in serious adverse events, which occurred in approximately 29% of patients in the intensive treatment group and 33% of patients receiving standard care.
Furthermore, subgroup analyses showed that the benefits of intensive BP lowering were consistent regardless of how much time had passed since the initial ICH event. Effects were also consistent across different baseline BP levels—patients whose baseline BP was already at a conventional target remained at considerable risk and benefitted from BP lowering. The researchers note that, for example, among those with systolic BP ≤130mmHg at baseline, recurrent stroke occurred in 13.9% of control-arm patients compared with 6.2% of patients receiving intensive treatment.
“Generally, guidelines recommend treatment to a target of less than 130/80mmHg, but our study showed that patients at or below this threshold can still face a significant risk of recurrent stroke,” Anderson added. “Preventing stroke recurrence requires us to address the persistent barriers to BP control, such as poor treatment adherence and therapeutic inertia. To achieve reliable control, we need to continue pursuing approaches that have shown promise, including fixed-dose combination therapies and structured treatment titration protocols.”
