At 30 study sites, 4,368 people with a history of ischemic stroke or transient ischemic attack were assigned to two different blood-pressure goals: below 120 or below 140 millimeters of mercury. Over a median of 3.9 years, the group treated toward the lower target had fewer major cardiovascular events, a finding that could help guide care for people at risk of another serious health problem.
A systolic blood-pressure reading measures the pressure in the arteries when the heart beats. High blood pressure is a major risk factor for heart disease and stroke. For people who have already had an ischemic stroke, caused by a blocked blood vessel, or a transient ischemic attack, often called a temporary warning stroke, reducing that risk is especially important. But pushing blood pressure lower may also bring risks, so the right target must be weighed carefully.
The randomized trial was led by Gisele Sampaio Silva, M.D., M.P.H., Ph.D., of Hospital Israelita Albert Einstein in São Paulo, Brazil, with colleagues. Researchers enrolled adults with elevated blood pressure and a previous ischemic stroke or transient ischemic attack at 30 sites. They assigned 2,172 people to intensive treatment, aiming for systolic pressure below 120 mmHg, and 2,196 to standard treatment, aiming for below 140 mmHg.
During follow-up, after the first three months, average systolic pressure was 122.0 mmHg in the intensive-treatment group and 135.2 mmHg in the standard-treatment group. The difference between the groups was 13.1 mmHg. The trial’s main outcome combined cardiovascular death, nonfatal heart attack, nonfatal stroke, and hospital admission for unstable angina or heart failure. At least one of those events occurred in 10.9% of the intensively treated group, compared with 13.5% of the standard-treatment group.
That amounted to 3.25 events per 100 person-years with intensive treatment and 4.11 with standard treatment. The researchers reported a hazard ratio of 0.79, a measure indicating a lower rate of the combined outcome in the intensive group. The results were published online Nov. 7 in the New England Journal of Medicine to coincide with the American Heart Association Scientific Sessions 2026 in Chicago, held Nov. 6 to 9.
The benefit came with a caution: a combined kidney outcome was more common among people receiving intensive treatment. It included a lasting 50% or greater drop in estimated kidney filtration, or progression to end-stage kidney disease. Overall rates of serious adverse events were similar between the groups.
“Achieving lower blood pressure safely requires appropriate medical supervision and additional monitoring, particularly of kidney function,” Sampaio said. The results suggest that a more intensive target may reduce future cardiovascular events for some people with a prior stroke or warning stroke, but they do not mean patients should change medication or targets on their own. Clinicians and patients will need to weigh the heart benefits against kidney risks and monitor treatment closely. Several authors disclosed ties to the biopharmaceutical industry.