INTENSIVE blood pressure control reduced major cardiovascular events after stroke, although tighter targets increased kidney complications.
New findings from the Phase III OPTIMAL-STROKE trial suggest that more aggressive systolic blood pressure management could improve cardiovascular outcomes in patients with previous ischemic stroke or transient ischemic attack (TIA). The results provide important evidence for secondary stroke prevention, while highlighting the need to balance cardiovascular benefits against potential renal complications.
The multicenter, randomized trial enrolled 4,368 adults with elevated blood pressure and a history of ischemic stroke or TIA across 30 sites in Brazil. Participants were assigned to intensive treatment targeting systolic blood pressure below 120 mm Hg or standard treatment targeting below 140 mm Hg.
The mean participant age was 63.9 years, and 47.9% were women. During follow-up, excluding the first three months, mean systolic blood pressure reached 122.0 mm Hg in the intensive group and 135.2 mm Hg in the standard group.
Over a median follow-up of 3.9 years, major cardiovascular events occurred in 10.9% of patients receiving intensive treatment, compared with 13.5% receiving standard treatment. This represented a 21% relative reduction in the primary composite outcome (hazard ratio: 0.79; 95% CI: 0.67–0.94; P=0.007).
The primary outcome included cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, and hospitalization for unstable angina or heart failure.
Despite the cardiovascular benefits, intensive treatment was associated with a higher incidence of kidney complications.
The composite renal outcome, defined as a sustained decline of at least 50% in estimated glomerular filtration rate or progression to end-stage renal disease, occurred more frequently in the intensive-treatment group.
However, the overall incidence of serious adverse events was similar between treatment groups.
These findings highlight an important consideration for clinicians managing hypertension in patients with established cerebrovascular disease. More intensive blood pressure reduction may improve cardiovascular protection, but renal function requires careful monitoring.
The OPTIMAL-STROKE findings strengthen evidence supporting lower systolic blood pressure targets for selected patients with previous ischemic stroke or TIA.
Although the trial demonstrated a significant reduction in major cardiovascular events, its open-label design and recruitment exclusively from Brazil should be considered when interpreting the findings.
For clinicians, the results support individualized blood pressure management that considers cardiovascular benefits, kidney function, and treatment tolerability. Further evaluation will help clarify which patients derive the greatest net benefit from intensive treatment.
Reference
Sampaio Silva G et al. Intensive Blood-Pressure Control in Patients with Previous Ischemic Stroke. N Engl J Med. 2026;doi:10.1056/NEJMoa2612924.
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