Design: Systematic review and individual participant data meta-analysis of 4 RCTs
Population: 2944 adults with previous spontaneous ICH; 75% Asian
Primary outcome: First recurrent stroke of any type
Effect: 6.5% vs 10.4%; HR 0.62 (95% CI 0.48 to 0.80)

RECAP-ICH pooled individual participant data from four randomised trials of long-term blood pressure lowering in 2944 adults with previous spontaneous intracerebral haemorrhage. Mean age was 60, 75% were Asian, and median follow-up was 42 months. It was published in The Lancet Neurology in September.

Systolic pressure was 11.2 mm Hg lower with treatment. First recurrent stroke occurred in 6.5% versus 10.4% (adjusted HR 0.62, 95% CI 0.48 to 0.80). The effect came mainly from fewer recurrent haemorrhages: 2.2% versus 5.6% (HR 0.39, 0.26 to 0.59). Serious adverse events were 28.9% versus 33.0%. Effects were consistent by age, sex, region, baseline pressure and time since the bleed, and a 1% absolute benefit was reached in about six months.

This is the strongest evidence yet that blood pressure control is the main secondary prevention after ICH, that benefit arrives quickly, and that it applies regardless of starting pressure. With most participants Asian, the results apply directly to Indian practice, where hypertensive ICH is common and follow-up often lapses.

Start or intensify antihypertensive treatment for every ICH survivor, whatever the baseline pressure.
Aim for a sustained systolic reduction of about 10 mm Hg or more.
Recheck within weeks; benefit begins within months.
Keep treatment going long term; stopping forfeits the benefit.

Why it matters

It confirms blood pressure control as the cornerstone of prevention after ICH, with benefit visible within months.

The statistics, in plain English

An HR of 0.62 means about 38% fewer recurrent strokes, and 0.39 for recurrent ICH means about 60% fewer repeat bleeds; both intervals are well below 1. In absolute terms, about 4 fewer strokes per 100 patients over 3.5 years. Only four trials contributed, so the result rests on a limited evidence base, but the individual-patient method and consistent subgroups strengthen it.