Stroke Survivors Did Better With a Lower Blood Pressure Target

CATEGORY: HEART & CIRCULATION

How far down should blood pressure go after a stroke? Guidelines have long said to get the top number under 140, and whether pushing well past that mark helps stroke survivors specifically had never been settled by a large trial built for them. Now it has been. Among 4,368 Brazilian adults who’d survived an ischemic stroke or a transient ischemic attack (a brief, stroke-like episode that resolves on its own), treating to a systolic target below 120 instead of below 140 brought a 21% lower risk of cardiovascular death, heart attack, stroke, or a hospital stay for chest pain or heart failure: 10.9% versus 13.5% of participants over a median of 3.9 years.¹

Three Pills Instead of Two, and 13 Points of Difference

The OPTIMAL-STROKE trial enrolled people at 30 centers across Brazil, typically about a year past their stroke and medically stable. A computer draw, not their doctors, set each person’s target. Everyone could see which goal they were chasing, while the committee judging every event could not. Reaching the stricter goal took an average of three blood-pressure medicines rather than two, and it worked: the intensive group averaged 122 over the trial against 135 in the standard group, a gap of about 13 points.¹ That’s the whole intervention. No new drug, just existing ones pushed further.

Fewer Strokes, Unchanged Deaths, a Cost Paid in Kidney Function

Events came in at 3.25 per 100 person-years under the lower target versus 4.11 under the standard one. Repeat strokes fell too: 4.7% versus 6.4%, a 27% lower risk. Deaths from cardiovascular causes alone didn’t budge, at 4.6% versus 4.7%, so the win came from fewer strokes and fewer heart-related hospital stays rather than from lives directly saved within these four years.¹ The kidneys paid part of the bill. Sustained drops in kidney function were nearly twice as common with intensive treatment, 3.9% versus 2.2%, and six people started dialysis versus three. Low blood sodium was also more frequent. Serious adverse events overall were even, and injurious falls were actually rarer in the intensive group, 1.0% versus 1.7%.

It Lands Where a Trial Three Times Its Size Did

ESPRIT, a Chinese trial of 11,255 high-risk adults in which about a quarter had already had a stroke, tested the same under-120 target and found 12% fewer major cardiovascular events over 3.4 years.² OPTIMAL-STROKE extends that answer to people whose defining risk is the stroke itself, and over a longer follow-up. Its authors note two limits: participants knew their assigned target, and everyone was treated in Brazil, so other health systems may see different results. Their bottom line was that pressure this low can be reached safely, but only with medical supervision and extra monitoring of kidney function along the way.

Key Takeaways

• For stroke and TIA survivors, aiming below 120 rather than below 140 meant fewer major cardiovascular events over about four years: 10.9% versus 13.5%, a 21% lower risk, with repeat strokes down 27%.
• Cardiovascular deaths were unchanged within the trial’s four years. The benefit came from preventing strokes and heart-related hospital stays.
• The stricter target required more medication and showed a kidney cost: sustained losses of kidney function were nearly twice as common, which is why the investigators emphasize close monitoring.

References

1. Sampaio Silva G, Machline-Carrion MJ, Santo K, et al. Intensive blood-pressure control in patients with previous ischemic stroke. New England Journal of Medicine. 2026; published online November 7, 2026:NEJMoa2612924. link
2. Liu J, Li Y, Ge J, et al.; ESPRIT Collaborative Group. Lowering systolic blood pressure to less than 120 mm Hg versus less than 140 mm Hg in patients with high cardiovascular risk with and without diabetes or previous stroke: an open-label, blinded-outcome, randomised trial. Lancet. 2024;404(10449):245–255. link