p.54 抽出テキスト

CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2025;152:e114–e218. DOI: 10.1161/CIR.0000000000001356 September 16, 2025 e167

In BP TARGET (Blood Pressure Target in Acute Stroke to Reduce Hemorrhage After Endovascular Therapy), the rate of any and symptomatic ICH was similar between post endovascular thrombectomy SBP goals of 110 to 129 mm Hg and 130 to 185 mm Hg. The ENCHANTED-2 MT (Enhanced Control of Hypertension and Thrombectomy Stroke Study) comparing post-endovascular thrombectomy SBP goals of <120 mm Hg and 140 to 180 mm Hg was stopped early due to an increased rate of worse global disability in the <120-mm Hg group (OR: 1.53 [95% CI: 1.18-1.97]).12 OPTIMAL BP (Enhanced Control of Hypertension and Thrombectomy Stroke Study), which compared post-endovascular throm­ bectomy SBP goals of <140 mm Hg versus 140 to 180 mm Hg, was also stopped early due to lower rates of improved outcomes at 90 days (modified Rankin scale score 0 to 2 of 39.4% in the <140mm Hg group versus 54.4% in the 140- to 180-mm Hg group).13 The BEST-II trial (Blood Pressure After Endovascular Stroke Therapy-II) showed that an SBP target of <140 mm Hg was potentially harmful based on the utility-weighted modified Rankin score, with a low probability of a future, larger trial showing benefit of post-endovascular thrombectomy BP lowering in a prespecified analysis.14

5.3.9.3 Secondary Stroke Prevention

Recommendations for Secondary Stroke Prevention References that support recommendations are summarized in the Evidence Table. COR LOE Recommendations

1 A 1 In patients with hypertension who have experienced

an ischemic stroke, transient ischemic attack (TIA), or ICH, treatment with a thiazide-type diuretic, ACEi, or ARB is recommended for lowering BP and reducing recurrent stroke and ICH risk.1–3

1 B-R 2 In patients with hypertension who have experienced

an ischemic stroke, TIA, or ICH, an office SBP/ DBP goal of <130/80 mm Hg is recommended to reduce the risk of recurrent stroke, ICH, and other vascular events.1,3–5

2a B-R 3 In patients with no history of hypertension who

have experienced an ischemic stroke, TIA, or ICH and have an average office SBP/DBP of ≥130/80 mm Hg, antihypertensive medication treatment can be beneficial to reduce the risk of recurrent stroke, ICH, and other vascular events.5–7

Synopsis

Each year in the United States, >750 000 adult pa­ tients experience a stroke, of which about 23% are recurrent strokes.8 More than 75% of ischemic stroke or ICH survivors have hypertension.9 Hypertension is the most important risk factor for stroke and ICH re­ currence.10,11 Yet, hypertension remains poorly con­ trolled in the outpatient setting among these patients, particularly among Black and Hispanic patients.12–14 For patients with prior stroke or TIA, there is concern that lower BP thresholds may increase the risk of stroke. New data from RCTs and large meta-analyses provide compelling evidence that neurologically stable patients with cerebrovascular disease benefit from an SBP/DBP goal of <130/80 mm Hg and that BP tar­ gets for stroke, ICH, and major vascular event prevention should be aligned with targets for prevention of other cardiovascular conditions. There is insufficient evidence to recommend a lower limit of BP within the normal range for patients with prior stroke or ICH. Like all pa­ tients with hypertension, antihypertensive drug regimens for those with cerebrovascular diseases should consider patient comorbidities, pharmacological agent class, and patient preference. The optimal timing for BP reduction after stroke is unclear; therefore, the recommendations in this section pertain to outpatient management of neu­ rologically stable patients.

Recommendation-Specific Supportive Text

1 Thiazide-type diuretics, ACEis, and ARBs have dem­

onstrated benefit in RCTs or systematic reviews of RCTs.1,2,4,15,16 Although CCBs are recommended for the treatment of hypertension, there are limited data on their efficacy for secondary stroke preven­ tion. However, the use of CCBs is acceptable for patients with stroke who require additional medication options.1,17

2 Data from 4 RCTs and recent meta-analyses support

the benefit of treating patients with prior stroke or TIA to achieve a BP goal of <130/80 mm Hg. The RESPECT (Recurrent Stroke Prevention Clinical Outcome),5 PAST-BP (Prevention After Stroke- Blood Pressure),18 and PODCAST (Prevention of Decline in Cognition after Stroke Trial)7 RCTs com­ pared intensive control of BP (SBP targets <120 to <130 mm Hg) with standard BP control (SBP targets <140 to <150 mm Hg) in patients with prior cerebrovascular disease. These trials reported nonsignificant tendencies toward lower recurrent stroke rates in the intensive treatment groups. However, a meta-analysis of these trials showed a significant reduction in recurrent stroke risk with an intensive versus standard target (relative risk: 0.78 [95% CI: 0.64-0.96]). An independent Cochrane analysis of SPS3 (Secondary Prevention of Small Subcortical Strokes), PAST-BP, and PODCAST reported a trend toward benefit of intensive BP targets (pooled relative risk for recurrent stroke, 0.80 [95% CI: 0.63-1.00]).1 In addition, the largest meta-analysis to date including >40 000 patients from 14 RCTs (including ischemic stroke, TIA, and

Downloaded from http://ahajournals.org by on October 7, 2026