ISC 2026 | Blood pressure management for stroke prevention: research gaps & clinical priorities

There are several questions, but I want to highlight three main lines of investigation. So first, implementation. Second, personalization of treatment. And third, the targets for blood pressure control. So in terms of implementation, we know that hypertension is the number one modifiable risk factor for stroke and cardiovascular disease. But unfortunately, most individuals with hypertension are not treated to target globally. In the same session last week during ISC, Paul Whelton provided overwhelming evidence for the benefits of blood pressure control, and Cheryl Bushnell emphasized the importance of active involvement of neurologists in hypertension treatment. Alexis Simpkins discussed the challenges for implementation, so we need more research on how to translate evidence into routine care, how to overcome therapeutic inertia, how to engage patients effectively, how to build scalable models of care, particularly in low- and middle-income countries. And Sara Hassani, in the same session, emphasized in her talk that several guidelines underscore the importance of implementation. So this marks a clear global shift from an era of evidence to an era of implementation with respect to blood pressure control. So research about optimal evidence-based implementation strategies in different scenarios is really necessary. So the second line of investigation is personalization of treatment. So there are still many evidence gaps. For instance, the timing and pace of blood pressure lowering. When should we start or intensify treatment after stroke or transient ischemic attack? How quickly should we reach target without increasing the risk of adverse events such as falls or syncope or kidney injury. And also, there’s a need for stronger evidence about how to manage blood pressure during the first days after stroke and during the transition from inpatient to outpatient. And also, there’s a need to personalize different targets with outcomes of quality of life, cognition, and medication burden. So in terms of the targets, we still need definitive evidence on the optimal systolic blood pressure target after stroke, particularly whether aiming for below 120 millimeters of mercury provides additional benefit compared to 130 millimeters of mercury. And also to which patients this more intensive target brings more benefits. So trials designated specifically for secondary stroke prevention, such as Optimal Stroke, are expected to provide important new data. And the Optimal Stroke is a Brazilian multicenter clinical trial that is conducted under the coordination of the Albert Einstein Hospital. So these were three main lines, but there are too many questions that need to be answered.

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