Intensive blood pressure lowering after intracerebral haemorrhage prevents recurrent stroke

Design

Systematic review and individual participant data meta-analysis of 4 randomised trials

Population

2944 adults with previous spontaneous intracerebral haemorrhage, 75% Asian

Primary outcome

First recurrent stroke of any type

Effect

6.5% vs 10.4%, HR 0.62 (95% CI 0.48–0.80); recurrent haemorrhage HR 0.39 (0.26–0.59)

RECAP-ICH pooled individual participant data from four randomised trials of long-term blood pressure lowering in 2944 patients with previous spontaneous intracerebral haemorrhage. Three-quarters were Asian, and median follow-up was 42 months. Treatment lowered systolic pressure by a mean of 11 mm Hg compared with control.

First recurrent stroke fell from 10.4% to 6.5% (HR 0.62). The benefit came mainly from fewer recurrent haemorrhages, 2.2% against 5.6% (HR 0.39). Serious adverse events were slightly less common with treatment. Effects were consistent across age, sex, region, baseline pressure and time since the bleed. A 1% absolute benefit accrued in about six months.

For Indian practice, where hypertensive intracerebral haemorrhage is common and blood pressure control after discharge is often poor, this is directly relevant. Blood pressure control is the single most effective secondary prevention after a bleed. It should start early, target intensively and be sustained, whatever the starting pressure.

• Start long-term antihypertensive treatment for every survivor of spontaneous intracerebral haemorrhage
• Aim for intensive control rather than simply below the hypertension threshold
• Treat even when baseline pressure seems modest, as effects were consistent
• Arrange home blood pressure monitoring and early follow-up after discharge
• Explain that most of the benefit is fewer repeat bleeds

Why it matters

Blood pressure control is the cornerstone of prevention after intracerebral haemorrhage, and benefit starts within months.

Don't overread it

Only four trials contributed data, and treatment strategies and targets varied between them.

The statistics, in plain English

HR 0.62 (95% CI 0.48–0.80) is a 38% relative reduction in recurrent stroke; in absolute terms about 4 fewer strokes per 100 patients over roughly 3.5 years. For recurrent haemorrhage, HR 0.39 (0.26–0.59) is a reduction of about 60%. Consistent subgroup effects make the result more generalisable, and individual participant data make it stronger than a standard meta-analysis.

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