Blood pressure lowering after intracerebral haemorrhage has been recommended without much certainty about how large the benefit is, who gets it, or how quickly it arrives. RECAP-ICH answers all three. It pooled individual participant data from four randomised trials of long-term blood pressure lowering in adults with previous spontaneous intracerebral haemorrhage — 2,944 participants, mean age 59.6, 75.3% Asian, median follow-up 42 months.
The achieved separation was a mean systolic difference of 11.2 mmHg (95% CI 10.7 to 11.7). First recurrent stroke of any type occurred in 96 of 1,487 on treatment (6.5%) and 152 of 1,457 controls (10.4%), adjusted hazard ratio 0.62 (95% CI 0.48 to 0.80, p=0.0002). Almost all of that came from recurrent haemorrhage: 33 events (2.2%) versus 81 (5.6%), adjusted hazard ratio 0.39 (95% CI 0.26 to 0.59, p<0.0001). Serious adverse events were if anything lower on treatment, 28.9% versus 33.0%.
Two further findings settle common hesitations. The benefit was consistent across age, sex, region, background antihypertensive treatment, baseline blood pressure and time since the index event — so a patient whose pressure is already near target, or who presents years later, is not excluded. And the estimated time to a 1% absolute risk reduction was 6.1 months (95% CI 3.5 to 14.8), which means the benefit accrues fast enough to matter even to a patient with limited life expectancy.
Three quarters of the cohort was Asian, which is unusual and makes this directly applicable in India, where haemorrhagic stroke makes up a larger share of all stroke than in Western series and where survivors are frequently discharged without a blood pressure target written down anywhere.
- Set and record an intensive blood pressure target for every survivor of spontaneous intracerebral haemorrhage, not only those with residual hypertension
- Aim for a sustained reduction of roughly 10 mmHg systolic — the magnitude that delivered the benefit here
- Do not defer treatment because the patient is already on an antihypertensive or already near target; the effect held across baseline pressure
- Start irrespective of how long ago the haemorrhage occurred — benefit was consistent across time since the index event
- Expect meaningful benefit within about six months, which justifies treatment even where life expectancy is limited
The statistics, in plain English
An adjusted hazard ratio of 0.62 with an interval of 0.48 to 0.80 sits entirely below 1.0, and the haemorrhage-specific figure of 0.39 (0.26 to 0.59) is one of the larger effects in stroke prevention. In absolute terms recurrent stroke fell by 3.9 percentage points over a median 42 months — roughly 26 patients treated to prevent one recurrence. The time-to-benefit estimate is worth understanding: it models how long treatment must continue before the cumulative difference reaches 1% and is the number that answers 'is this worth starting in a frail patient'. Its interval, 3.5 to 14.8 months, is wide, but even its pessimistic end is inside two years. Note this is a pooled analysis of four trials, and only four of 24 eligible trials supplied individual data.
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