After a stroke, a lower blood pressure goal cut repeat heart attacks and strokes by about a fifth, a large trial finds
A second, smaller study found that adding a cheap, decades-old ‘water pill’ helped twice as many survivors reach their blood pressure goal.
Two studies presented Nov. 7 at the American Heart Association’s Scientific Sessions in Chicago add evidence that stroke survivors benefit from pushing their blood pressure lower than many doctors now aim for, and suggest one inexpensive way to get there.
High blood pressure is the biggest risk factor for a repeat stroke that a person can change, the heart association says. Nearly 1 in 4 stroke survivors will have another stroke, and up to 80% of strokes can be prevented, the association says. Blood pressure is written as two numbers. The top, or systolic, number is the pressure when the heart beats; the bottom, or diastolic, number is the pressure between beats. Both are measured in millimeters of mercury, written mm Hg.
How low should it go?
The larger study, called OPTIMAL-STROKE, enrolled 4,368 people at 30 sites in Brazil who had had a stroke caused by a clot or a “mini-stroke” and who had high blood pressure. Half were picked at random to have doctors aim for a top number below 120, and half for below 140. Their average age was about 64, and about 48% were women.
Over a median of 3.9 years, 10.9% of the lower-target group had a heart attack, stroke, heart-related death or a hospital stay for chest pain or heart failure, compared with 13.5% of the standard group, a 21% lower risk. Strokes alone were about 27% less common. The results were also published in the New England Journal of Medicine. But kidney problems, mostly drops in kidney function, were about 76% more common with the lower target, and the researchers said that shows the need for individual treatment and careful monitoring. Rates of serious side effects, injuries and sudden blood pressure drops on standing were similar.
“Many clinicians have worried that lowering blood pressure too far after an ischemic stroke could reduce blood flow to the brain and trigger another event,” said Dr. Otavio Berwanger, who led the trial’s steering committee. “In clinically stable patients, we saw fewer ischemic strokes, not more.”
A cheap ‘water pill’
The second study, REDUCE, tested spironolactone, a long-available diuretic, or “water pill,” that helps the body get rid of salt and water. Doctors usually add it only when blood pressure stays high on three other drugs. The trial enrolled 160 stroke survivors at five U.S. hospitals, including Yale New Haven Hospital and the Hospital of the University of Pennsylvania. Half added spironolactone to their care and half got usual care.
After three months, the spironolactone group’s average top number at home was about 126, compared with about 133 for usual care. Fifty-two percent reached the recommended goal of below 130/80, compared with 30%. Low blood pressure, lightheadedness and high potassium were more common with the drug, so people taking it need regular potassium checks, said Dr. Jordana Cohen of the University of Pennsylvania, a co-lead author. The study was small, both patients and doctors knew who got the drug, it ended early, and it was not designed to show whether the drug prevents strokes. It has not yet been reviewed by outside scientists for a journal.
What survivors can do
Cohen said the results show the value of routinely checking blood pressure at home. Stroke survivors can ask their doctor what blood pressure goal is right for them, whether their current medicines are reaching it and, if they have kidney disease, how a lower goal could affect their kidneys. The heart association has a guide, “Preventing Another Stroke,” on its stroke.org website.
Source: American Heart Association Scientific Sessions summary of the OPTIMAL-STROKE and REDUCE trials, Nov. 8, 2026 and American Heart Association news release on the REDUCE trial, Nov. 7, 2026.