More Time in Target Blood Pressure Range Cuts Recurrent Stroke After Intracerebral Hemorrhage

A pooled analysis of 4 randomized trials found that more time with systolic blood pressure (SBP) below 130 mmHg was associated with a lower risk of recurrent stroke after intracerebral hemorrhage (ICH). Higher cumulative SBP load, a measure of sustained blood pressure exposure above target, was associated with greater risk.¹

Xia Wang, MMed, a doctoral research fellow at The George Institute for Global Health, in Sydney, Australia, presented the findings at the World Stroke Congress (WSC 2026), held October 21-23, 2026, in Seoul, Republic of Korea. All told, researchers analyzed 2810 participants from 4 randomized controlled trials of blood pressure-lowering treatment for secondary prevention after ICH: PROGRESS, RESPECT, ESPRIT, and TRIDENT.

In the analysis, time in target range (TTR) was defined as the percentage of follow-up time with SBP below 130 mmHg, and cumulative SBP load was defined as the extent of exposure to SBP above that target. The primary outcome was time to first recurrent stroke; Cox proportional hazards models were adjusted for age, sex, ethnicity, hypertension, alcohol use, and treatment assignment.

Median participant age was 60 years (interquartile range, 53-67), 918 participants (32.7%) were female, median baseline SBP was 142 mmHg, and 2,164 participants (77.0%) had hypertension. Recurrent stroke occurred in 233 participants (8.3%) and major adverse cardiovascular events (MACE) in 300 (10.7%) during follow-up.

Higher TTR was associated with a lower risk of recurrent stroke (hazard ratio [HR], 0.94; 95% CI, 0.90-0.99; P =.012), MACE (HR, 0.95; 95% CI, 0.92-0.99; P =.024), cardiovascular death (HR, 0.92; 95% CI, 0.85-0.99; P =.029), and recurrent ICH specifically (HR, 0.90; 95% CI, 0.84-0.97; P =.007).Conversely, higher cumulative SBP load was associated with greater risk of recurrent stroke (HR, 1.06; 95% CI, 1.04-1.09) and MACE (HR, 1.06; 95% CI, 1.04-1.08).¹

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The investigators concluded that after ICH, more time with SBP below 130 mmHg and lower cumulative SBP load were strongly associated with fewer recurrent vascular events, supporting durable blood pressure control as a measurable target for secondary prevention.

PROGRESS, published in 2001, was among the first large randomized trials to show that blood pressure-lowering treatment reduces the risk of recurrent stroke in patients with a history of stroke or transient ischemic attack, including those with prior ICH; a perindopril-based regimen that also included indapamide produced a larger blood pressure reduction and stroke risk reduction than perindopril alone.² RESPECT and ESPRIT are more recent randomized trials of blood pressure-lowering treatment after ICH, conducted in Japan and China, respectively; detailed design information for those 2 trials was not independently available at the time of this article's publication.¹

TRIDENT, the most recently completed of the 4 trials, randomized 1670 participants with prior spontaneous ICH and systolic BP between 130 and 160 mmHg to a once-daily single pill combining low doses of telmisartan, amlodipine, and indapamide, or to placebo, added to standard care.³

In results published in the New England Journal of Medicine earlier this year, the triple-pill group had a lower rate of recurrent stroke over a median follow-up of 2.5 years (4.6% vs 7.4%; HR, 0.61; 95% CI, 0.41-0.92), driven mainly by fewer recurrent ICH events (1.8% vs 4.4%; HR, 0.40; 95% CI, 0.22-0.73). The triple pill was associated with more treatment discontinuations due to adverse events, primarily hypotension and rises in serum creatinine.³

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REFERENCES
1. Wang X, et al. The association between time in target range and systolic blood pressure load and recurrent stroke after intracerebral haemorrhage. Presented at: World Stroke Congress 2026 (WSC 2026); October 21-23, 2026; Seoul, Republic of Korea.
2. PROGRESS Collaborative Group. Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6105 individuals with previous stroke or transient ischaemic attack. Lancet. 2001;358:1033-1041.
3. The Trident Research Group. Three low-dose antihypertensive agents in a single pill after intracerebral hemorrhage. N Engl J Med. 2026;394:1571-1582. doi:10.1056/NEJMoa2515043