Blood pressure lowering after intracerebral haemorrhage has been standard advice for years, but the questions that determine how hard to push have been open: does it work in everyone, how quickly does benefit accrue, and does it cost anything. RECAP-ICH answered them with individual participant data. Four eligible randomised trials contributed data on 2,944 adults with previous spontaneous intracerebral haemorrhage, mean age 59.6 years, 75.3% Asian, followed for a median 42 months.
The treatment achieved a mean systolic difference of 11.2 mm Hg (95% CI 10.7 to 11.7). First recurrent stroke of any type occurred in 96 of 1,487 (6.5%) on intensive lowering against 152 of 1,457 (10.4%) on control: adjusted hazard ratio 0.62 (95% CI 0.48 to 0.80, p=0.0002). Almost all of that came from preventing recurrent haemorrhage — 33 events (2.2%) against 81 (5.6%), adjusted HR 0.39 (0.26 to 0.59). Serious adverse events were no more common on intensive treatment, at 28.9% against 33.0%.
Two further findings matter for how you act on this. The effect was consistent across every prespecified subgroup tested — age, sex, region, baseline blood pressure, background antihypertensive use, and crucially time since the index event. And the estimated time to a 1% absolute risk reduction was 6.1 months (95% CI 3.5 to 14.8). Benefit arrives fast enough to be worth pursuing even in a patient with limited life expectancy, and consistency across time since event means it is never too late to start.
The population makes this unusually applicable here. Three-quarters of participants were Asian, and intracerebral haemorrhage accounts for a far larger share of stroke in India than in Western series — hypertensive, often in younger patients, often poorly controlled long before the bleed. This is one of the rare occasions when the evidence base matches the patient in front of you. The practical failure in Indian practice is not knowing to lower blood pressure; it is that control lapses in the months after discharge, when the patient is out of the stroke service and back with whoever will see them. That is the part to fix.
- Set an intensive, titrated blood pressure target after intracerebral haemorrhage rather than accepting usual care.
- Start regardless of how long ago the haemorrhage was; the benefit did not depend on time since the event.
- Aim for a sustained reduction of roughly 10 mm Hg systolic, which is what produced this effect.
- Reassure patients and colleagues that serious adverse events were not increased by the intensive strategy.
- Build the follow-up: benefit accrues from about six months, so the risk is treatment drifting after discharge.
The statistics, in plain English
A hazard ratio of 0.62 with an interval of 0.48 to 0.80 is a solid result: the whole interval sits well below 1.0. The absolute figures matter more for a consultation — 10.4% down to 6.5%, so about 26 patients treated to prevent one recurrent stroke over roughly three and a half years. The haemorrhage-specific result is stronger still at 0.39. Pooling individual patient data rather than published summaries is what makes the subgroup analyses trustworthy here; ordinary meta-analyses cannot test consistency across patient characteristics properly. Note the limits: only four trials qualified, and three-quarters of participants were Asian, so this is best evidence for Asian populations and extrapolated elsewhere.
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