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Targeting a systolic BP below 120 mm Hg significantly reduced major cardiovascular events in stroke and TIA survivors, according to the OPTIMAL-STROKE trial. Over ~4 years, intensive treatment cut the primary endpoint rate from 13.5% to 10.9% — a meaningful win. However, the same aggressive strategy showed no significant benefit in patients with type 2 diabetes and high cardiovascular risk in the companion OPTIMAL-DIABETES trial.
Two large Brazilian trials tested whether targeting a systolic blood pressure (BP) below 120 mm Hg beats the standard target of below 140 mm Hg — and the answer depends heavily on who the patient is. In OPTIMAL-STROKE, intensive BP lowering significantly reduced major adverse cardiovascular events (MACE) in patients with a prior ischemic stroke or TIA over nearly 4 years. Experts called it a landmark result, particularly because stroke patients have historically been excluded from aggressive BP-lowering trials due to concerns about cerebral perfusion.
The companion OPTIMAL-DIABETES trial, however, told a different story. In nearly 9,500 patients with type 2 diabetes and high cardiovascular risk, the same intensive strategy produced no statistically significant reduction in MACE (6% vs. 6.7%). A pre-specified meta-analysis combining these results with prior trials (BPROAD, ACCORD BP) did suggest a ~16% relative risk reduction, hinting that the benefit may exist but is harder to detect in this population.
By the Numbers:
Why it matters: OPTIMAL-STROKE is the first adequately powered trial to show cardiovascular benefit of aggressive BP lowering specifically in stroke/TIA survivors — a population long excluded from such trials. The renal trade-off and real-world implementation challenges mean updated clinical guidelines and clear monitoring protocols will be essential.
