Recurrent stroke risk falls 38% with stronger BP control after brain hemorrhage

Clinical takeaway: After intracerebral hemorrhage, sustained blood pressure control should remain a priority for secondary prevention. More intensive treatment reduced recurrent stroke even among patients starting with systolic BP ≤130 mm Hg, with clinically meaningful benefit emerging within months.

Survivors of intracerebral hemorrhage (ICH) remain at substantial risk of another stroke, making long-term blood pressure management one of the most important modifiable targets for secondary prevention. A meta-analysis of randomized trials strengthens the case for sustained blood pressure (BP) control and suggests benefit extends across a broad range of patients.

Researchers pooled individual data from four randomized trials involving 2,944 adults with previous spontaneous ICH. Over a median follow-up of 42 months, recurrent stroke occurred in 6.5% of patients assigned to more intensive BP treatment versus 10.4% with less intensive treatment or standard care, a 38% relative risk reduction.

The benefit was driven largely by fewer recurrent brain hemorrhages, which occurred in 2.2% versus 5.6% of patients, respectively, representing a 61% relative reduction. Average systolic BP during follow-up was 127 mm Hg with more intensive treatment versus 138 mm Hg in controls.

Benefits emerged relatively early: the estimated time to achieve a 1% absolute reduction in recurrent stroke was 6.1 months. Treatment effects were consistent across age, sex, baseline BP, background antihypertensive treatment, and time since the initial ICH.

Serious adverse events were not increased, occurring in 28.9% of patients receiving more intensive treatment and 33.0% of controls.

The results do not establish a new optimal BP target, but they suggest that reaching a conventional target should not necessarily end efforts to optimize BP management after ICH. Benefits were consistent across baseline BP levels, including among patients starting with systolic BP ≤130 mm Hg.

“Generally, guidelines recommend treatment to a target of less than 130/80 mm Hg, but our study showed that patients at or below this threshold can still face a significant risk of recurrent stroke,” said senior author Craig Anderson, MD, PhD, of The George Institute for Global Health.

Source: Wang X, et al. (2026 Aug 12) Lancet Neurol. Intensive blood pressure lowering after spontaneous intracerebral haemorrhage for secondary stroke prevention (RECAP-ICH): a systematic review and individual participant data meta-analysis