Lancet Neurology meta-analysis of 4 RCTs finds 38% lower recurrent stroke risk with intensive BP lowering after ICH

Four RCTs tested either fixed-dose antihypertensives or target-driven strategies. Mean achieved systolic pressure was 127 mm Hg versus 138 mm Hg, a 11.2 mm Hg difference sustained up to six years. Recurrent stroke of any type occurred in 6.5% of intensively treated patients versus 10.4% in controls, equating to a 38% relative reduction driven chiefly by a 61% drop in recurrent ICH. Serious adverse events remained comparable (29% versus 33%). The analysis challenges current guideline targets of <130/80 mm Hg; patients already at or below this threshold still experienced a 7.7 percentage-point absolute risk reduction. Benefits were consistent across time since index event and baseline pressure levels, indicating that residual risk persists even when conventional targets are met. Global ICH incidence exceeds 3 million cases yearly, with survivors facing roughly 25% lifetime risk of fatal recurrence. Low- and middle-income countries bear nearly double the burden, where adherence and therapeutic inertia remain primary obstacles. Fixed-dose combinations and structured titration protocols, already tested in related stroke trials such as INTERACT2 and PROGRESS, offer scalable routes to close this gap. The ongoing TRIDENT trial, the only study limited to spontaneous ICH, will test whether tighter targets plus combination therapy produce further gains; results expected 2027 will clarify whether current findings translate into updated guideline thresholds.