TTR and Systolic Blood Pressure Load Control Improve Recurrent Stroke Risk

Lower systolic blood pressure (SBP) is associated with fewer recurrent vascular events in patients with intracerebral hemorrhage (ICH), according to new data.¹

Presented at the World Stroke Congress (WSC) 2026 in Seoul, South Korea, by Xia Wang, MMed, a doctoral research fellow at the George Institute in Australia, these data represent an analysis of 4 randomized controlled trials investigating blood pressure-lowering treatment for secondary prevention after ICH.¹

“Long-term blood pressure control after ICH is summarized by mean SBP, but this may miss visit-to-visit burden,” Wang and colleagues wrote. “We examined whether SBP time in target range (TTR) and cumulative SBP load are associated with recurrent vascular events after ICH.”¹

The present study included patients from the ESPRIT, PROGRESS, RESPECT, and TRIDENT randomized controlled trials, a series of trials from several international institutes worldwide evaluating the role of blood pressure lowering in ICH treatment. PROGRESS, a 2005 study published in theLancet, enrolled patients from 172 centers across Asia, Australia, and Europe to receive either blood pressure-lowering medication – namely, perindopril – or placebo. After 4 years of follow-up, the investigators saw that active treatment resulted in significantly fewer strokes than placebo. Active treatment also substantially reduced the risk of major vascular events.²

ESPRIT, which enrolled 11,255 patients over 3.4 years, contrasted intensive blood pressure control against standard blood pressure control in patients with hypertension and their respective impacts on stroke. The team ultimately saw that more significant blood pressure control was associated with a substantial reduction in hemorrhagic stroke risk without increasing the risk of ischemic stroke. The RESPECT trial randomized 1263 patients between 2 blood pressure control groups, targeting <140/90 mmHg or <120/80 mmHg, respectively.^3,4

Investigators in the TRIDENT trial administered a once-daily pill containing 3 antihypertensive agents, namely telmisartan, amlodipine, and indapamide, to patients for 2 weeks before randomly assigning them to continue this therapy or cross over to placebo. Among the 1670 patients in the trial, those receiving the triple pill saw a greatly reduced risk of recurrent stroke and major cardiovascular events following ICH.⁵

Wang and colleagues included 2810 patients from the combined 4 trials in their analysis. TTR was defined as the percentage of follow-up with SBP <130 mmHg and cumulative SBP load as exposure above target. The primary outcome was time to first recurrent stroke. The team used Cox models to adjust for age, sex, ethnicity, hypertension, alcohol use, and treatment.¹

Among the included patients, median age was 60 years, median baseline SBP was 142 mmHg, and 2164 patients had hypertension. Recurrent stroke occurred in 233 patients, while major adverse cardiovascular events occurred in 300 patients. Wang and colleagues saw that higher TTR was associated with a lower risk of recurrent stroke (HR, 0.94; 95% CI, 0.9-0.99; P = .012), major adverse cardiovascular events (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 (HR, 0.9; 95% CI, 0.84-0.97; P = .007). Higher cumulative SBP load was associated with higher recurrent stroke (HR, 1.06; 95% CI, 1.04-1.09) and major adverse cardiovascular events (HR, 1.06; 95% CI, 1.04-1.08).¹

“After ICH, more time below SBP 130 mmHg and lower cumulative SBP load were strongly associated with fewer recurrent vascular events, supporting durable BP control as a measurable secondary-prevention target,” Wang and colleagues wrote.¹

References

1. Wang X. The Association Between Time in Target Range and Systolic Blood Pressure Load and Recurrent Stroke After Intracerebral Haemorrhage. Presented at the World Stroke Congress (WSC) 2026, Seoul, South Korea. October 21-23, 2026.

2. PROGRESS Collaborative Group. Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6105 individuals with previous stroke or transient ischaemic attack. The Lancet. 2001;358(9287):1033-1041. doi:10.1016/s0140-6736(01)06178-5

3. Li J, Lei L, Li Y, Zhang H, Yan X, Sun Y, He D, Du L, Hu J, Qi L, Yu X, Xiu G, Jiao Y, Yu L, Zhou W, Feng L, Guan Z, Liu A, Luo Q, Niu M, Tian H, Liu J, Li J; ESPRIT Collaborative Group. Effect of Intensive Blood Pressure Control on Stroke: A Prespecified Secondary Analysis of the ESPRIT Trial. J Am Coll Cardiol. 2025 Oct 28;86(17):1405-1417. doi: 10.1016/j.jacc.2025.07.055

4. Kitagawa K, Yamamoto Y, Arima H, et al. Effect of Standard vs Intensive Blood Pressure Control on the Risk of Recurrent Stroke: A Randomized Clinical Trial and Meta-analysis. JAMA Neurol. 2019;76(11):1309-1318. doi:10.1001/jamaneurol.2019.2167

5. The Trident Research Group. Three low-dose antihypertensive agents in a single pill after intracerebral hemorrhage. NEJM. 2026;394(16):1571-1582. doi:10.1056/nejmoa2515043