AHA 2026: Intensive Blood Pressure Control Reduces Events After Ischemic Stroke

Intensive blood pressure control targeting a systolic blood pressure (SBP) below 120 mm Hg reduced major cardiovascular events compared with a target below 140 mm Hg in patients with previous ischemic stroke or transient ischemic attack (TIA), according to OPTIMAL-STROKE trial results presented at the American Heart Association (AHA) Scientific Sessions 2026 and published in the New England Journal of Medicine.¹

“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, MD, PhD, chair of the OPTIMAL study Steering Committee, executive director at The George Institute for Global Health in London, and chair in clinical trials at Imperial College London, UK.²

OPTIMAL-STROKE trial design and primary outcome results

The investigator-initiated, open-label OPTIMAL-STROKE trial randomized 4368 patients 1:1 at 30 sites in Brazil from August 2019 through August 2022, with outcomes adjudicated by a blinded clinical events committee.¹ Eligible adults had a history of ischemic stroke or TIA, were clinically stable for at least 48 hours, and had an SBP of 130 to 180 mm Hg.¹ Patients with a modified Rankin scale score of 4 or more, known secondary hypertension, or an estimated glomerular filtration rate (eGFR) below 20 mL/min/1.73 m² were excluded.¹

Mean age was 63.9 years, 47.9% of patients were women, and the median time from the qualifying event to randomization was 1.1 years. Excluding the first 3 months, mean SBP during follow-up was 122.0 mm Hg in the intensive group and 135.2 mm Hg in the standard group, a mean difference of 13.1 mm Hg (95% CI, 12.5–13.8). Patients in the intensive group used a mean of 3.0 antihypertensive medications vs 2.2 in the standard group.¹

Over a median follow-up of 3.9 years, the primary composite of cardiovascular death, nonfatal myocardial infarction (MI), nonfatal stroke, or hospitalization for unstable angina or heart failure occurred in 10.9% (236/2172) of the intensive group and 13.5% (297/2196) of the standard group.¹ The hazard ratio (HR) was 0.79 (95% CI, 0.67–0.94; P = .007).¹ Event rates were 3.25 and 4.11 per 100 person-years, respectively.¹

Secondary outcomes, renal events, and safety of intensive SBP lowering after stroke

The key secondary composite of cardiovascular death, nonfatal MI, or nonfatal stroke occurred in 9.8% vs 11.8% of patients (HR, 0.81; 95% CI, 0.68–0.98; P = .03). Cardiovascular death did not differ between groups (4.6% vs 4.7%; HR, 0.96; 95% CI, 0.73–1.26), so formal hierarchical testing stopped. Stroke occurred in 4.7% vs 6.4% of patients (HR, 0.73; 95% CI, 0.56–0.94), a difference driven by ischemic stroke, which investigators described as supportive rather than confirmatory.¹

Serious adverse events occurred in 15.1% of the intensive group and 15.3% of the standard group. The composite renal outcome occurred in 3.9% vs 2.2% of patients (HR, 1.76; 95% CI, 1.24–2.50), driven mainly by sustained eGFR reductions of at least 50%, and 6 vs 3 patients began long-term dialysis. Injurious falls were less frequent with intensive treatment (1.0% vs 1.7%), while serum sodium below 130 mmol/L occurred in 3.3% vs 2.2% of patients.¹

“Our study shows that for many people who have already experienced an ischemic stroke or TIA, aiming for a systolic blood pressure below 120 mm Hg can provide additional cardiovascular protection compared with the conventional target of below 140 mm Hg. However, we emphasize that achieving lower blood pressure safely requires appropriate medical supervision and additional monitoring, particularly of kidney function,” said Gisele Sampaio, MD, PhD, MSc, principal investigator, professor of neurology at the Federal University of São Paulo, and head of neurology clinical research at the Albert Einstein Hospital in São Paulo, Brazil.²

The investigators cited the open-label design, enrollment limited to Brazil, and reduced statistical power after blinded sample size revisions as limitations.¹ They added the findings support considering a lower SBP target in clinically stable patients, with monitoring of kidney function and electrolytes as treatment is intensified.¹ Separate analyses have associated time in therapeutic range and SBP load control with recurrent stroke risk.³

References

1. Sampaio Silva G, Machline-Carrion MJ, Santo K, et al. Intensive blood-pressure control in patients with previous ischemic stroke. N Engl J Med. Published online November 7, 2026. doi:10.1056/NEJMoa2612924

2. American Heart Association. Intensive blood pressure control in stroke survivors lowered risk of cardiovascular events. Published November 7, 2026. Accessed November 7, 2026. https://newsroom.heart.org/news/intensive-blood-pressure-control-in-stroke-survivors-lowered-risk-of-cardiovascular-events

3. HCPLive. TTR and systolic blood pressure load control improve recurrent stroke risk. https://www.hcplive.com/view/ttr-and-systolic-blood-pressure-load-control-improve-recurrent-stroke-risk. Published October 21, 2026. Accessed November 7, 2026.