Common Diuretic Linked to Home Blood Pressure Lowering After Stroke

Adding spironolactone to post-stroke care lowered home systolic blood pressure (SBP) at 3 months compared with standard care in adults with uncontrolled hypertension after ischemic stroke or intracerebral hemorrhage, according to REDUCE trial results presented as a late-breaking abstract at the American Heart Association (AHA) Scientific Sessions 2026.¹

At 3 months, home SBP was 125.6 mm Hg with spironolactone and 133.3 mm Hg with standard care (mean difference, −7.7 mm Hg; 95% CI, −11.6 to −3.8; P = .0002). More participants receiving spironolactone reached a blood pressure (BP) target below 130/80 mm Hg (52% vs 30%; P = .01), and the SBP reduction persisted at 6 months.¹

“Lowering blood pressure is the most important step in preventing another stroke, yet many survivors struggle to reach recommended blood pressure targets after a stroke. When spironolactone was added to post-stroke care, we saw a meaningful drop in blood pressure that may lower the risk of future strokes and heart attacks,” said Jordana B. Cohen, MD, MSCE, FAHA, co-lead author and associate professor of medicine and epidemiology at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia.²

REDUCE trial design and spironolactone blood pressure results

REDUCE was a multicenter, randomized, open-label trial at 5 US centers enrolling adults with prior ischemic stroke or intracerebral hemorrhage and uncontrolled hypertension from April 2021 through October 2025.^1,2 Participants were randomized 1:1 to spironolactone-based BP treatment or standard care, and the primary outcome was home SBP at 3 months.¹ Enrollment ended early at 160 of a planned 200 participants.²

Mean age was 63 years, 37% of participants were female, 29% were Black, and 54% had intracerebral hemorrhage. Mean baseline home SBP was 136 mm Hg, and participants were receiving a mean of 1 antihypertensive medication at enrollment.¹

Home diastolic blood pressure (DBP) at 3 months was 77.0 mm Hg with spironolactone and 81.1 mm Hg with standard care (mean difference, −4.1 mm Hg; 95% CI, −7.0 to −1.2; P = .0056). At 6 months, home SBP was 124.0 vs 130.9 mm Hg (mean difference, −6.9 mm Hg; 95% CI, −10.6 to −3.2; P = .0004).¹ Home DBP at 6 months was 76.3 vs 80.2 mm Hg (mean difference, −3.9 mm Hg; 95% CI, −6.8 to −1.0; P = .0096).¹

Medication burden, subgroups, and safety of spironolactone after stroke

Participants receiving spironolactone used fewer concomitant antihypertensive medications at 3 months (1.7 vs 2.1; mean difference, −0.4; 95% CI, −0.7 to −0.02; P = .04).¹ According to the AHA, total antihypertensive medication use, including spironolactone, was slightly higher in the spironolactone group (2.6 vs 2.1).² Treatment effects were greater among participants randomized fewer than 90 days after stroke and those with a body mass index of 30 kg/m² or higher (interaction P < .05 for both).¹

Serious adverse events occurred in 15% of the spironolactone group and 16% of the standard care group. Hypotension (8% vs 1%), lightheadedness (5% vs 1%), and hyperkalemia (4% vs 0%) were more frequent with spironolactone.¹ According to the investigators, hyperkalemia did not result in any life-threatening complications.¹

“We were surprised to see that blood pressure dropped twice as much as we expected. In an exploratory analysis, the blood pressure drop was larger in people who started this medication within three months after a stroke,” said Cohen. “We hope these findings encourage healthcare professionals to consider adding spironolactone sooner. In addition, we hope the results illustrate the importance of routine home blood pressure monitoring to reduce the increased cardiovascular disease risks associated with any level of high blood pressure, the #1 modifiable risk factor for cardiovascular disease.”²

REDUCE compared spironolactone with usual care rather than with a different added antihypertensive, about 15% of participants lacked 3-month BP readings, and the trial was not designed to assess recurrent stroke or myocardial infarction. The findings are preliminary until published in a peer-reviewed journal.²

Spironolactone is typically added as a fourth-line antihypertensive, and aldosterone synthase inhibitors such as lorundrostat have also lowered BP in patients with chronic kidney disease and uncontrolled hypertension.^2,3

In the same AHA late-breaking session, OPTIMAL-STROKE found an SBP target below 120 mm Hg reduced major cardiovascular events compared with a target below 140 mm Hg after ischemic stroke or transient ischemic attack.⁴

References

1. Cohen JB. A randomized controlled trial of spironolactone-based blood pressure management after stroke. Presented at: American Heart Association Scientific Sessions 2026; November 7, 2026; Chicago, IL. Abstract 21380.

2. American Heart Association. Can a low-cost diuretic medication help to lower blood pressure after a stroke? Published November 7, 2026. Accessed November 7, 2026. https://newsroom.heart.org/news/can-a-low-cost-diuretic-medication-help-to-lower-blood-pressure-after-a-stroke

3. HCPLive. Lorundrostat lowers BP, albuminuria in CKD with uncontrolled hypertension. https://www.hcplive.com/view/lorundrostat-lowers-bp-albuminuria-in-ckd-with-uncontrolled-hypertension. Published October 23, 2026. Accessed November 7, 2026.

4. HCPLive. AHA 2026: Intensive blood pressure control reduces events after ischemic stroke. https://www.hcplive.com/view/aha-2026-intensive-blood-pressure-control-reduces-events-after-ischemic-stroke. Published November 7, 2026. Accessed November 7, 2026.