Intensive blood pressure-lowering cut recurrent stroke risk by around 38% after brain haemorrhage

Meta-analysis reinforces long-term blood pressure control as a cornerstone of secondary stroke prevention

Intensive, long-term blood pressure-lowering treatment reduced the risk of recurrent stroke by 38%, without increasing serious adverse events, in people who have survived an intracerebral haemorrhage (ICH). The findings of the major meta-analysis were published today in The Lancet Neurology.¹

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 blood pressure targets.

During a follow-up period of up to six years, recurrent stroke of any type occurred in 6.5% of patients receiving intensive blood pressure-lowering compared with 10.4% of those receiving less intensive treatment or standard care (the control arm). This translated to a 38% reduction in recurrent stroke risk, with consistent benefits observed across all studies.

Professor Craig Anderson, senior author and Senior Professorial Fellow at The George Institute said the findings provide compelling evidence for more intensive blood pressure management after ICH.

“

Intracerebral haemorrhage is one of the deadliest forms of stroke, with limited treatment options and a high risk of recurrence among survivors. Our analysis shows that intensive blood pressure treatment can prevent 16 recurrent strokes for every 1,000 patients treated within the first year alone. These findings reinforce the central role of blood pressure control in secondary stroke prevention.

By:

Professor Craig Anderson

Senior Professorial Fellow, The George Institute for Global Health

During follow-up, average systolic blood pressure (SBP) was 127 mm Hg in the intensive treatment group and 138 mm Hg in the control group, representing a mean difference of 11.2 mm Hg.

The reduction in recurrent stroke was mainly driven by an approximately 61% lower risk of ICH among patients receiving intensive treatment. Importantly, 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.

The findings have important global implications. More than three million people experience ICH each year and there’s an estimated 17 million survivors.² Among these survivors, approximately one quarter will later die from recurrent stroke or cardiovascular disease.³

The ICH burden falls disproportionately on low- and middle-income countries, where high blood pressure is often inadequately controlled.4 Rates of ICH are almost twice as high in these countries compared with high-income nations.⁴

Subgroup analysis showed that the benefits of intensive blood pressure lowering were consistent regardless of how much time had passed since the initial ICH event.

Effects were consistent across different baseline blood pressure levels. Notably, patients whose baseline blood pressure was already at conventional target remained at considerable risk and benefitted from blood pressure lowering. For example, among those with systolic blood pressure ≤130 mm Hg at baseline, recurrent stroke occurred in 13.9% of control patients compared with 6.2% of patients receiving intensive treatment.

Professor Anderson added that the findings challenge assumptions made by current guidelines.

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Generally, guidelines recommend treatment to a target of less than 130/80 mm Hg, but our study showed that patients at or below this threshold can still face a significant risk of recurrent stroke.

Preventing stroke recurrence requires us to address the persistent barriers to blood pressure 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.

By:

Prof Anderson

The TRIDENT study, led by The George Institute for Global Health, was the only trial in this analysis that exclusively enrolled patients with spontaneous ICH. The remaining trials included people with either ischaemic stroke or ICH at baseline.

References

1. Wang X et al. Intensive blood pressure lowering after spontaneous intracerebral haemorrhage for secondary stroke prevention (RECAP-ICH): a systematic review and individual participant data meta-analysis. Lancet Neurol. 2026. https://www.thelancet.com/journals/laneur/article/PIIS1474-4422(26)00244-9/fulltext

2. Feigin VL et al. World Stroke Organization: Global Stroke Fact Sheet 2025. Int J Stroke. 2025. https://doi.org/10.1177/17474930241308142

3. Kuohn LR, et al. Cause of death in spontaneous intracerebral hemorrhage survivors: multistate longitudinal study. Neurology. 2020. https://doi.org/10.1212/WNL.0000000000010736