This individual participant data (IPD) meta-analysis of 4 RCTs (n=2,944) evaluated long-term intensive blood pressure (BP) lowering vs. placebo or standard management for secondary stroke prevention in adults with prior spontaneous intracerebral haemorrhage (ICH), with median follow-up of 42 months.
Intensive BP lowering reduced recurrent stroke (6.5% vs. 10.4%; adjusted HR 0.62, 95% CI 0.48–0.80; p=0.0002), driven largely by fewer recurrent ICH events (2.2% vs. 5.6%; adjusted HR 0.39, 95% CI 0.26–0.59; p<0.0001). A clinically meaningful 1% absolute risk reduction was achieved in just 6.1 months (95% CI 3.5–14.8). Serious adverse events were numerically lower in the treatment group (28.9% vs. 33.0%).
Only 4 trials met full IPD eligibility criteria from 24 assessed, limiting breadth. The cohort was predominantly Asian (75.3%), which may limit generalizability to other populations. All trials used varied treatment strategies (fixed-dose vs. titrated targets), introducing potential heterogeneity in the intervention.
Start or intensify BP-lowering therapy after ICH without delay — meaningful protection accrues within ~6 months and is consistent regardless of age, sex, baseline BP, or time since the index bleed. Sustained, long-term BP control should be the cornerstone of post-ICH secondary prevention.
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