Stroke survivors who received intensive blood pressure-lowering treatment were significantly less likely to suffer another stroke, heart attack or other major cardiovascular event, according to late-breaking research presented at the American Heart Association's Scientific Sessions 2026 in Chicago. The trial, simultaneously published in the New England Journal of Medicine, found that targeting a systolic blood pressure below 120 mm Hg reduced the risk of major cardiovascular events by about 21% compared with standard treatment targeting below 140 mm Hg.
The OPTIMAL-Stroke trial enrolled 4,368 adults in Brazil who had previously experienced an ischemic stroke or transient ischemic attack (TIA) and had elevated blood pressure. Over an average follow-up of 3.9 years, cardiovascular events occurred in 10.9% of the intensive treatment group versus 13.5% of the standard treatment group. Recurrent strokes were also lower in the intensive group, at 4.7% versus 6.4%, driven by fewer ischemic strokes. Serious adverse events were similar overall, though kidney-related events increased in the intensive group, highlighting the need for careful monitoring and individualized care.
The findings carry substantial implications for the nearly 185,000 Americans who suffer recurrent strokes each year. High blood pressure is the single most important modifiable risk factor for stroke, and current guidelines already recommend intensive control for many patients. The 2025 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults advises maintaining systolic pressure under 130 mm Hg and encourages levels below 120 mm Hg for people at increased cardiovascular risk. This trial provides robust randomized evidence supporting that aggressive target specifically in stroke survivors.
"Controlling blood pressure after a stroke is especially important because it can help prevent another stroke, prevent other cardiovascular complications and protect patients' lives," said Otavio Berwanger, M.D., Ph.D., chair of the OPTIMAL study Steering Committee. Principal investigator Gisele Sampaio, M.D., Ph.D., emphasized that achieving lower blood pressure safely requires medical supervision and monitoring of kidney function.
The study has limitations, including that not all participants in the intensive group reached the below-120 target, and results may not generalize to populations outside Brazil. Still, for patients and clinicians, the message is clear: for many stroke survivors, a lower blood pressure target may offer greater protection. As Sampaio noted, patients should know their blood pressure, take prescribed medications consistently and discuss individual targets with their healthcare team. Resources such as Preventing Another Stroke and Understanding Blood Pressure Readings can help patients navigate that conversation. The trial's findings could inform future updates to secondary prevention guidelines and reinforce the critical role of blood pressure management in reducing the global burden of recurrent cardiovascular events.
