In Simple Terms
High blood pressure can raise the chance of another stroke and heart problems, but the same treatment goal may not suit everyone. One study found benefits from aiming lower after a stroke, while another did not find the same benefit for people with type 2 diabetes. The right plan depends on each person’s health and needs regular medical follow-up.
Why Finding High Blood Pressure Is Only the First Step
Blood pressure is more than a number written down during a clinic visit. After a stroke, pressure that stays high may raise the risk of another one, making blood pressure control an important part of preventing future problems. Yet knowing that treatment matters does not make it easy to reach recommended targets. About one-third of people who have had a stroke do not meet those targets, Bruce Ovbiagele of the University of California, San Francisco’s Weill Institute for Neurosciences noted.
Sticking with treatment can also become harder over time. One year after a stroke, about one in five survivors has stopped taking blood-pressure-lowering medication. That observation does not explain why people stop, but it shows that success depends on more than choosing a drug. It also calls for regular follow-up, clear communication with patients, and coordination among the medical teams caring for them.
Care becomes more complicated when a person has other health conditions. Someone with type 2 diabetes may need a treatment plan that accounts for several factors. Lowering blood pressure to very low levels can also require monitoring kidney function and certain substances in the blood. The numbers alone cannot settle the question of what treatment to use. To understand the findings, it matters who took part in each study, what the researchers measured, and what the study could not establish.
Testing a Common Drug Earlier After a Stroke
The REDUCE study tested a different approach to when doctors might use an older, inexpensive drug called spironolactone. It belongs to a class of medicines known as diuretics and is usually used later in blood-pressure treatment, after three other drugs have failed to bring pressure under control. In REDUCE, researchers asked whether starting it earlier after a stroke could help patients reach a lower blood-pressure level.
After three months, participants given spironolactone were more likely than those receiving usual post-stroke care to have a blood-pressure reading below 130/80 mmHg. Jordana Cohen of the Perelman School of Medicine at the University of Pennsylvania presented the findings. This result concerns blood-pressure readings: the trial was not designed to determine whether the drug actually reduces heart attacks, recurrent strokes, or deaths.
Cohen noted that previous research had linked a drop of just 7 mmHg in blood pressure to a 38% lower risk of another stroke. But that association should be distinguished from what REDUCE tested. The study focused on lowering blood pressure; it did not measure cardiovascular outcomes. Its findings were also presented as a scientific conference abstract and had not yet been published in a medical journal at the time of the presentation.
Even so, the fact that spironolactone is widely available and inexpensive caught the attention of researchers and commentators. Ovbiagele said that trying it earlier offers a promising direction to consider, particularly because many patients struggle to meet blood-pressure targets and some stroke survivors stop taking their medication. The findings do not mean that every patient should automatically start spironolactone after a stroke. Choosing a treatment and monitoring the response remain responsibilities of the medical team, especially when a patient has other health conditions.
Is Lower Blood Pressure Better After a Stroke?
A larger Brazilian trial took on a different question: Does aiming for a systolic blood pressure of 120 mmHg or lower lead to better outcomes than aiming for the traditional target of below 140 mmHg? Systolic pressure is the top number in a blood-pressure reading. It reflects the pressure in the arteries as the heart pumps blood. Gisele Sampaio of the Federal University of São Paulo led the OPTIMAL-STROKE study, which was published in The New England Journal of Medicine.
Over four years of follow-up, participants treated to reach the lower target were less likely to die or experience cardiovascular events than those treated to lower their blood pressure to a level below 140 mmHg. The nonfatal events included in the study were heart attack, stroke, and hospital admission for chest pain or heart failure. So the comparison was not limited to blood-pressure readings in a clinic; it also considered important health outcomes observed over several years.
Still, aiming for a lower reading is not a decision to make without medical supervision. It may require monitoring kidney function, since changes in treatment can affect measures related to the kidneys. Otavio Berwanger of Imperial College London, who chaired the OPTIMAL study’s steering committee, said the trial found no increase in end-stage kidney failure, the need for dialysis, or deaths. However, some kidney-function markers and electrolyte levels did change. Electrolytes are salts and minerals in the body, and the changes were consistent with the effects of diuretics or differences in how much water patients drank.
These details matter when interpreting the result. The study supports the benefit of a lower blood-pressure target for the group it examined, but that does not remove the need to balance potential benefits with medical monitoring. Checking kidney function and electrolytes is part of using treatment safely. It is not a minor detail to overlook when trying to bring blood pressure down to a more ambitious level.
A Different Result for People With Diabetes
By contrast, the OPTIMAL-DIABETES study did not find that targeting a systolic pressure below 120 mmHg was better than aiming for a level below 140 mmHg in people with type 2 diabetes. The researchers assessed major cardiovascular events and deaths and found no reduction in those outcomes with the lower target. This study was also published in The New England Journal of Medicine.
Carla Santo of Hospital Israelita Albert Einstein in São Paulo presented the trial results and noted that the best blood-pressure target for people with diabetes remains a matter of debate. The neutral result does not mean that treating high blood pressure is unimportant for these patients, or that lowering it has no general benefit. It means that, in the group studied, the comparison between the two specific targets did not show that the lower one was better at reducing major events or deaths.
This conclusion differs from the OPTIMAL-STROKE finding, even though both trials compared a systolic target below 120 mmHg with one below 140 mmHg. The contrast shows why the same numbers may not translate into a single rule for every patient. Diabetes, a history of stroke, and other health factors may affect how doctors assess an appropriate target. The available results do not explain every difference between the studies, but they are a reason not to assume that an approach that helped one group will produce the same result in another.
Shauna Nesbitt of UT Southwestern Medical Center pointed out that the studies involved different participant groups, including differences between men and women and between younger and older adults. She also raised the importance of longer follow-up. In her view, the diabetes finding does not necessarily overturn earlier trials suggesting benefits from more intensive treatment. Instead, it may encourage a more careful approach rather than grouping different patients together. The question is not only how low blood pressure should go, but also for whom, under what circumstances, and with what level of follow-up.
Treatment Takes a Team, Not Just a Target
Even when treatment goals are clear, the way care is organized can get in the way of reaching them. Ovbiagele noted that responsibility for a stroke survivor’s care may shift among different specialties. A neurologist may oversee treatment in the hospital, then the patient may move to primary care after leaving. Other specialists, such as kidney doctors, may also become involved in monitoring kidney function or adjusting medication. That raises a practical question: Who coordinates prescriptions, reviews readings, and makes sure the patient can keep following the treatment plan?
Cheryl Bushnell of Wake Forest University said the challenge is not always knowing what should be done, but organizing how to do it. Lowering blood pressure in people who have had a stroke can be complicated in everyday practice, particularly when responsibilities are shared by a neurologist, a kidney specialist, and a primary care doctor. If information is not shared clearly, it may be difficult to adjust treatment or monitor its effects, even when a medication is available and the target is known.
This issue carries added weight in the United States, where care may be spread across a hospital and several different clinics. And a result achieved in a clinical trial does not automatically translate into successful treatment everywhere. Putting it into practice requires a follow-up plan, medication reviews, and access to kidney-function and electrolyte tests when a patient’s condition calls for them. These are not administrative details separate from treatment; they are part of keeping blood pressure under control safely.
What the Studies Show Together
Taken together, the three studies offer a more nuanced picture than the simple rule that lowering blood pressure as much as possible helps everyone. REDUCE tested starting spironolactone earlier after a stroke and found that more participants reached a reading below 130/80 mmHg after three months. But it did not test whether this change affected cardiovascular events. OPTIMAL-STROKE, meanwhile, suggested a benefit from targeting a systolic pressure of 120 mmHg or lower rather than below 140 mmHg in people who had had a stroke, based on outcomes tracked over four years.
In contrast, OPTIMAL-DIABETES found that, among people with type 2 diabetes, a target below 120 mmHg did not reduce major cardiovascular events or deaths compared with a target below 140 mmHg. The findings should not be collapsed into a single verdict, nor should the conclusion of one study be applied to a group it did not examine. It is also important to note that the studies measured different things: changes in blood-pressure levels, complications, or death. Those outcomes are not interchangeable.
The central message is that controlling high blood pressure remains essential, but finding the best plan requires considering a person’s full health picture. A history of stroke, diabetes, kidney function, the ability to keep taking medication, and coordination among caregivers all help determine whether a lower target is appropriate and how to reach it. Turning one target into a prescription for everyone could overlook the differences highlighted by the studies.
The Bottom Line
The research presented in Chicago underscores the importance of controlling blood pressure after a stroke. A common drug such as spironolactone may help improve blood-pressure readings when started earlier, although its effect on actual health outcomes remains to be determined. OPTIMAL-STROKE found a potential benefit from aiming for a systolic pressure of 120 mmHg or lower rather than below 140 mmHg over four years, while OPTIMAL-DIABETES did not find the same benefit among people with type 2 diabetes. Together, the different results highlight the need to tailor treatment and monitor patients, while improving coordination among clinicians so people do not get lost between stages of care.