Intensive Blood Pressure Targets Research Articles

Intensive Blood Pressure Targets and Kidney Disease.

In November 2017, the American College of Cardiology/American Heart Association (ACC/AHA) released new guidelines that lowered BP targets to <130/80 mm Hg for virtually all adults, including patients with CKD. These guidelines were largely on the basis of results from the Systolic BP Intervention

Hypertension Guidelines in the United States and Canada: Are We Getting Closer?

See related article, pp e13–e115 The American College of Cardiology/American Heart Association (ACC/AHA) with 9 other organizations recently released new guidelines for the prevention, detection, evaluation, and management of hypertension in adults, including new blood pressure (BP) treatment thresholds and targets.1 The previous US guidelines released in 2014 caused some controversy by recommending relaxed treatment goals for several high-risk subgroups, including patients aged ≥60 years and those with diabetes mellitus or kidney disease.2 Instead, the new ACC/AHA guidelines provide a single, more intensive BP target for BP management, regardless of age or comorbid conditions. Overall, these new guidelines are more aligned with the 2017 Hypertension Canada guidelines3 and share similar key messages given that both sets of guidelines were derived from the same clinical evidence. However, some differences between ACC/AHA and Hypertension Canada are notable and warrant further discussion. First, diagnosis of hypertension. In the ACC/AHA guidelines, hypertension diagnosis is set as BP ≥130/801 versus ≥140/90 mm Hg in Hypertension Canada and other international guidelines.3,4 However, most people in the BP bracket of 130 to 139/80 to 89 mm Hg (stage 1 hypertension according to the new ACC/AHA guidelines) will have low cardiovascular risk, and both guidelines encourage health behavior modification for low-risk patients. Although observational studies demonstrate a doubling in cardiovascular risk in patients with pressures of 130 to 139/80 to 89 mm Hg compared with optimal readings, the absolute 10-year cardiovascular risk increase is relatively small. In a recent meta-analysis of 74 trials (n=306 273 participants),5 BP lowering for primary prevention was associated with decreased risk for cardiovascular disease and mortality only if baseline systolic BP was ≥140 mm Hg. The benefits for BP lowering when systolic BP was below a threshold of 140 mm Hg were only experienced in …

Effect of Standard vs Intensive Blood Pressure Control on Cerebral Blood Flow in Small Vessel Disease

Blood pressure (BP) lowering is considered neuroprotective in patients with cerebral small vessel disease; however, more intensive regimens may increase cerebral hypoperfusion. This study examined the effect of standard vs intensive BP treatment on cerebral perfusion in patients with severe small vessel disease. To investigate whether standard vs intensive BP lowering over 3 months causes decreased cerebral perfusion in small vessel disease. This randomized clinical trial took place at 2 English university medical centers. Patients were randomized via a central online system (in a 1:1 ratio). Seventy patients with hypertension and with magnetic resonance imaging-confirmed symptomatic lacunar infarct and confluent white matter hyperintensities were recruited between February 29, 2012, and October 21, 2015, and randomized (36 in the standard group and 34 in the intensive group). Analyzable data were available in 62 patients, 33 in the standard group and 29 in the intensive group, for intent-to-treat analysis. This experiment examines the 3-month follow-up period. Patients were randomized to standard (systolic, 130-140 mm Hg) or intensive (systolic, <125 mm Hg) BP targets, to be achieved through medication changes. Cerebral perfusion was measured using arterial spin labeling; the primary end point was change in global perfusion between baseline and 3 months, compared between treatment groups by analysis of variance. Linear regression compared change in perfusion against change in BP. Magnetic resonance imaging scan analysis was masked to treatment group. Among 62 analyzable patients, the mean age was 69.3 years, and 60% (n = 37) were male. The mean (SD) systolic BP decreased by 8 (12) mm Hg in the standard group and by 27 (17) mm Hg in the intensive group (P < .001), with mean (SD) achieved pressures of 141 (13) and 126 (10) mm Hg, respectively. Change in global perfusion did not differ between treatment groups: the mean (SD) change was -0.5 (9.4) mL/min/100 g in the standard group vs 0.7 (8.6) mL/min/100 g in the intensive group (partial η2, 0.004; 95% CI, -3.551 to 5.818; P = .63). No differences were observed when the analysis examined gray or white matter only or was confined to those achieving target BP. The number of adverse events did not differ between treatment groups, with a mean (SD) of 0.21 (0.65) for the standard group and 0.32 (0.75) for the intensive group (P = .44). Intensive BP lowering did not reduce cerebral perfusion in severe small vessel disease. isrctn.org Identifier: ISRCTN37694103.

Abstract P226: Aggressive Blood Pressure Control Status Post-acute Aortic Dissection May be Associated With Acute Kidney Injury: A Pilot Study

Management of acute aortic dissection includes appropriate blood pressure control (120/80 mmHg per AHA guidelines) but this is not based on evidence. Excessive lowering of blood pressure may contribute to organ malperfusion. The kidneys are the most commonly affected organs, causing refractory hypertension and acute kidney injury (AKI). Recent landmark blood pressure trials with intensive pressure goals have a significant incidence of AKI. This pilot study tested the hypothesis that achieved systolic blood pressure less than 120 mmHg has a higher incidence of AKI than those treated systolic pressures &gt; 120 mmHg. Methods: Patients were identified via surgical log. Retrospective chart review was performed on patients in the acute setting following dissection. Daily average blood pressures were calculated. Patients were included if they underwent surgical repair of aortic dissection and survived the first 24 hours. Patients were excluded if they demonstrated shock physiology or required renal replacement therapy in the first 24 hours. Serum creatinine and clinical course (including anti-hypertensive regimen) were recorded. The primary endpoint was in-hospital occurrence of AKI (defined per KDIGO criteria) in the acute setting status post aortic dissection in patients receiving anti-hypertensive therapy. An unadjusted odds ratio was calculated. Data on potential confounders and covariates (baseline sCR, contrast exposure etc) were also collected. Results: From 2013-2017, 37 cases of surgically repaired aortic dissection were identified and 16 cases met inclusion/exclusion criteria. The incidence of AKI in patients treated to an average systolic blood pressure less than 120mmHg was 75% compared with 50% in those with pressure greater than 120 mmhg. OR =3.0 [95% CI 0.3612-24.9];p=0.3019. Covariates and potential confounders were balanced between groups but given the small numbers additional statistical adjustments were not performed. Conclusion: The incidence of AKI was numerically higher in the group of patients achieving more intensive blood pressure targets. Our study was limited by small sample size and selection bias. Both of these issues can be addressed if we apply similar methodologies to address the same question on a lager sample size.

Visit-to-Visit Office Blood Pressure Variability and Cardiovascular Outcomes in SPRINT (Systolic Blood Pressure Intervention Trial).

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01206062.

The J-shaped Curve for Blood Pressure and Cardiovascular Disease Risk: Historical Context and Recent Updates.

The definition and treatment of hypertension have both changed dramatically over the last century, with recent trials suggesting benefit for lower blood pressure (BP) targets than ever before considered. However, tempering the enthusiasm for more intensive BP targets are long-held concerns that BP reduction below a certain threshold may pose dangers, the so-called "J-curve." In this review, we summarize the evidence for a J-curve in the treatment of hypertension. The Systolic Blood Pressure Intervention Trial (SPRINT) reported that achieving a systolic BP target of 120mmHg reduces cardiovascular disease in high-risk individuals, supporting more intensive BP reduction. However, contemporary observational studies consistently demonstrate a BP J-curve, the threshold of which is often close to the SPRINT target. Studies also suggest that the BP level of this J-curve may vary based on patient characteristics, including age and comorbidities. There is also more compelling evidence for the specific presence of a J-curve between diastolic BP and coronary events, in contrast to conflicting evidence of a J-curve with systolic BP and cardiovascular disease more generally. There is increased risk of coronary events below a diastolic BP of 60-70mmHg. In comparison, the presence of a systolic J-curve is less clear and some persons at high risk may actually benefit from systolic levels down to 120mmHg. Therefore, we suggest a personalized approach to BP management considering individual risks, benefits, and preferences when choosing therapeutic targets. Further, well-designed studies are required to support our suggestions and to define J-curve thresholds more clearly.

Abstract P180: Impact of Intensive Systolic Blood Pressure Treatment on Cardiovascular Disease and Mortality in the US Population

Introduction: Hypertension is the most important risk factor for cardiovascular disease (CVD), the leading cause of morbidity and mortality among US adults. Clinical trials suggest that intensive systolic blood pressure (BP) management significantly reduces risk of CVD and mortality in patients at high risk for CVD. However, the impact of intensive BP lowering in the US population is uncertain. Hypothesis: More intensive treatment of systolic BP provides great benefits in the reduction of CVD and total deaths in the US population aged ≥40 years. Methods: We pooled follow-up data in 31,851 individuals from four US cohort studies (ARIC, CHS, Framingham Heart Study, and MESA) to estimate annual incidence rates of major CVD (combined stroke, coronary heart disease, and heart failure) by sex, race (white and non-white), and age groups (40-49, 50-59, 60-69, and ≥70 years). We retrieved mortality data from annual death statistics reported by the CDC. We combined nationally-representative survey data from three NHANES cycles (2009-2010, 2011-2012, 2013-2014) to estimate the proportions of US adults aged ≥40 years in each of 10 systolic BP categories (range &lt;120 to ≥160 mm Hg). A Bayesian network meta-analysis of antihypertensive clinical trials was used to estimate relative risks for CVD and mortality comparing each of the 10 systolic BP categories, after adjusting for baseline risk in included trials. Using these data sources, we calculated the population attributable fractions and number of events (and deaths) that could be reduced by treating systolic BP ≥140 mmHg to more intensive systolic BP targets in the US population. Results: Treating systolic BP to 120-124 mm Hg showed the largest reduction in number of CVD events and total deaths compared to higher targets (Table). Conclusions: In conclusion, intensive treatment of systolic BP could prevent a large number of CVD events and total deaths in the US population.

Effect of Intensive Versus Standard Clinic-Based Hypertension Management on Ambulatory Blood Pressure: Results From the SPRINT (Systolic Blood Pressure Intervention Trial) Ambulatory Blood Pressure Study.

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01835249.

The Case for Low Blood Pressure Targets

The "totality" of hypertension clinical trial endpoint data has shown that the absolute benefit of pharmacological blood pressure (BP) lowering is directly related to the BP level and baseline cardiovascular risk, albeit with attenuation of the relative risk reduction per unit of BP lowering in patients with diabetes and chronic kidney disease. Absolute risk reductions with pharmacological treatment are greater with advancing age. Cardiovascular risk and mortality reductions attributable to pharmacological BP lowering have been demonstrated for progressively lower BP levels extending well below the conventional BP threshold (140/90mm Hg) for hypertension. Hypertension endpoint trials have shifted from determining the relative clinical benefits of various antihypertensive drugs to exploring whether lower than conventional BP targets in persons with BP levels spanning the prehypertensive to much higher BP strata confer clinical benefit. The more recent of these trials were "relatively" agnostic to the drugs used for BP lowering although several trials provided, but did not mandate the use of, specific agents. Pharmacological treatment benefit has been demonstrated at pretreatment BP levels even lower than the intensive SPRINT BP target (<120mm Hg) and a growing body of evidence suggests that substantial risk reduction can be achieved by maintaining a normal BP over time (rather than waiting for BP to exceed 140/90mm Hg before treating). Thus there is a compelling rationale to lower the BP threshold not just for a therapeutic goal but also for the initiation of pharmacological intervention.

Cost-effectiveness analysis of different systolic blood pressure targets for people with a history of stroke or transient ischaemic attack: Economic analysis of the PAST-BP study.

BackgroundThe PAST-BP trial found that using a lower systolic blood pressure target (<130 mmHg or lower versus <140 mmHg) in a primary care population with prevalent cerebrovascular disease was associated with a small additional reduction in blood pressure (2.9 mmHg).ObjectivesTo determine the cost effectiveness of an intensive systolic blood pressure target (<130 mmHg or lower) compared with a standard target (<140 mmHg) in people with a history of stroke or transient ischaemic attack on general practice stroke/transient ischaemic attack registers in England.MethodsA Markov model with a one-year time cycle and a 30-year time horizon was used to estimate the cost per quality-adjusted life year of an intensive target versus a standard target. Individual patient level data were used from the PAST-BP trial with regard to change in blood pressure and numbers of primary care consultations over a 12-month period. Published sources were used to estimate life expectancy and risks of cardiovascular events and their associated costs and utilities.ResultsIn the base-case results, aiming for an intensive blood pressure target was dominant, with the incremental lifetime costs being £169 lower per patient than for the standard blood pressure target with a 0.08 quality-adjusted life year gain. This was robust to sensitivity analyses, unless intensive blood pressure lowering reduced quality of life by 2% or more.ConclusionAiming for a systolic blood pressure target of <130 mmHg or lower is cost effective in people who have had a stroke/transient ischaemic attack in the community, but it is difficult to separate out the impact of the lower target from the impact of more active management of blood pressure.

Arterial hypertension: which targets in over-75-year people?

Arterial hypertension has always been considered the main risk factor in cardiovascular prevention. However, the goals of anti-hypertensive treatment (targets) in the elderly has long been under discussion. The results of the studies in favor of the hypothesis "the lower the better" than those that argue against the existence of the phenomenon of the J-curve, that is, the hypothesis according to which mortality increases to too low pressure values lower than 115/75 mmHg, are still controversial. However, in elderly patients the association between blood pressure lowering and increased cardiovascular events seems to depend on the general health status, that means the presence of comorbidity, frailty and / or disability. Recent data from the SPRINT study show that the benefit of an intensive blood pressure target (SBP <120 mmHg) compared to a usual target (SBP <140 mmHg), appears to be greater in the oldest hypertensive patients (≥75 years). The cardio-geriatric functional assessment can provide useful information to better stratify the elderly and to define more accurately the pressure targets, the choice is individual.

Review of the Systolic Blood Pressure Intervention Trial for Hypertension Management: How Low to Go for Patients With Stroke?

One of the great successes of modern medicine is the development of effective pharmacological treatments to lower blood pressure (BP). Of the modifiable risk factors for cardiovascular disease, elevated BP or hypertension has the highest population attributable risk,1 and a near continuous relationship with rates of stroke and coronary heart disease from levels of 115 mm Hg systolic and 75 mm Hg diastolic BP.2 Overviews of randomized trials are consistent in showing that lowering systolic BP by 5 to 10 mm Hg reduces the risk of stroke by one third, irrespective of disease history, initial BP level, or type of agent used.3–5 Moreover, more intensive long-term BP lowering can result in additional benefits proportional to the size of fall in BP.4–6 Despite this body of evidence, there has been longstanding controversy (and consternation) over the levels to which BP should be brought down by treatment for the prevention of cardiovascular disease. Because there has been limited randomized evidence, guideline committees have been challenged in defining BP targets below 130 to 140 mm Hg to manage individual patients.7 Concerns over diminishing net benefit being overtaking by excessive harm with increasing reductions in BP is supported by a physiological argument over critical thresholds for organ perfusion and secondary analysis of randomized trials suggesting a J-shaped relationship with cardiovascular events.8 Moreover, recent trials of more intensive BP lowering, including the Action to Control Cardiovascular Risk on Type 2 Diabetes (ACCORD)9 and Secondary Prevention of Small Subcortical Strokes (SPS3),10 failed to show significant reductions in rates of ischemic stroke with systolic BP reductions below 120 and 130 mm Hg, respectively. The main result of the Systolic …

The Stroke Prevention Programme: a programme of research to inform optimal stroke prevention in primary care

BackgroundThe management of cardiovascular (CV) risk factors in community populations is suboptimal. The aim of this programme was to explore the role of three approaches [use of a ‘polypill’; self-management of hypertension; and more intensive targets for blood pressure (BP) lowering after stroke] to improve prevention of CV disease (CVD) in the community.Research questions(1) Is it more cost-effective to titrate treatments to target levels of cholesterol and BP or to use fixed doses of statins and BP-lowering agents (polypill strategy)? (2) Will telemonitoring and self-management improve BP control in people on treatment for hypertension or with a history of stroke/transient ischaemic attack (TIA) in primary care and are they cost-effective? (3) In people with a history of stroke/TIA, can intensive BP-lowering targets be achieved in a primary care setting and what impact will this have on health outcomes and cost-effectiveness?DesignMixed methods, comprising three randomised controlled trials (RCTs); five cost-effectiveness analyses; qualitative studies; analysis of electronic general practice data; a screening study; a systematic review; and a questionnaire study.SettingUK general practices, predominantly from the West Midlands and the east of England.ParticipantsAdults registered with participating general practices. Inclusion criteria varied from study to study.InterventionsA polypill – a fixed-dose combination pill containing three antihypertensive medicines and simvastatin – compared with current practice and with optimal implementation of national guidelines; self-monitoring of BP with self-titration of medication, compared with usual care; and an intensive target for systolic BP of &lt; 130 mmHg or a 10 mmHg reduction if baseline BP is &lt; 140 mmHg, compared with a target of &lt; 140 mmHg.ResultsFor patients known to be at high risk of CVD, treatment as per guidelines was the most cost-effective strategy. For people with unknown CV risk aged ≥ 50 years, offering a polypill is cost-effective [incremental cost-effectiveness ratio (ICER) of £8115 per quality-adjusted life-year (QALY)] compared with a strategy of screening and treating according to national guidelines. Both results were sensitive to the cost of the polypill. Self-management in people with uncontrolled hypertension led to a 5.4 mmHg [95% confidence interval (CI) 2.4 to 8.5 mmHg] reduction in systolic BP at 1 year, compared with usual care. It was cost-effective for men (ICER of £1624 per QALY) and women (ICER of £4923 per QALY). In people with stroke and other high-risk groups, self-management led to a 9.2 mmHg (95% CI 5.7 to 12.7 mmHg) reduction in systolic BP at 1 year compared with usual care and dominated (lower cost and better outcome) usual care. Aiming for the more intensive BP target after stroke led to a 2.9 mmHg (95% CI 0.2 to 5.7 mmHg) greater reduction in BP and dominated the 140 mmHg target.ConclusionsPotential for a polypill needs to be further explored in RCTs. Self-management should be offered to people with poorly controlled BP. Management of BP in the post-stroke population should focus on achieving a &lt; 140 mmHg target.Trial registrationCurrent Controlled Trials ISRCTN17585681, ISRCTN87171227 and ISRCTN29062286.FundingThe National Institute for Health Research (NIHR) Programme Grants for Applied Research programme. Additional funding was provided by the NIHR National School for Primary Care Research, the NIHR Career Development Fellowship and the Department of Health Policy Research Programme.

Different systolic blood pressure targets for people with history of stroke or transient ischaemic attack: PAST-BP (Prevention After Stroke—Blood Pressure) randomised controlled trial

Objective To assess whether using intensive blood pressure targets leads to lower blood pressure in a community population of people with prevalent cerebrovascular disease.Design Open label randomised controlled trial.Setting 99...

Hypertension: Rest before blood pressure measurement: a lesson from SPRINT.

The SPRINT data suggest a cardiovascular benefit of intensive blood pressure (BP) lowering in high-risk individuals. The BP measurement protocol, however, likely resulted in lower BP values than would normally be obtained in the clinic. Intensive BP targets might not be as safe if routine BP measurements are used.

Blood pressure management in acute intracerebral hemorrhage: current evidence and ongoing controversies.

Spontaneous intracerebral hemorrhage (ICH) is associated with high rates of morbidity and mortality. Although treatment options are limited, a potential acute medical intervention is blood pressure (BP) reduction. The review will summarize the current evidence and remaining knowledge gaps with respect to acute BP management in acute ICH. More than 3000 patients were enrolled in seven prospective randomized-controlled clinical trials assessing the safety and efficacy of intensive BP reduction (target <140-150 mmHg systolic) compared with current guideline-recommended BP target (<180 mmHg) in acute ICH. Overall, these trials demonstrated that intensive BP reduction is well tolerated and may be associated with a modest improvement in functional outcomes. There is still no conclusive evidence that aggressive BP reduction is associated with attenuation of hematoma growth or mortality rates. Delayed time to enrolment and difficulty in achieving intensive BP targets in a timely fashion without stringent antihypertensive protocols may partially account for the absence of proven benefit. Recent trials have shown that BP lowering (<140 mmHg systolic) is well tolerated and may improve functional outcomes. Ongoing trials will provide insight into the overall benefit of early aggressive BP reduction in acute ICH.

Effects of Intensive Blood Pressure Lowering on Intracerebral Hemorrhage Outcomes: A Meta-Analysis of Randomized Controlled Trials.

Elevation of blood pressure (BP) is common after intracerebral hemorrhage (ICH). Early BP treatment may be beneficial after ICH, but the effect of intensive BP lowering on ICH outcomes is not known and no systematic review or meta-analysis was published regarding this issue. We conducted a meta-analysis to compare the effect of more versus less intensive BP targets on clinical outcomes in patients with ICH. Mortality, unfavorable outcome and adverse events were analyzed. Meta-analysis was performed in terms of the odds ratio (OR) and 95% confidence interval (CI). Five eligible studies were included and analyzed, involving 3243 patients to use systolic BP (SBP) < 140 mmHg as target BP and 142 patients to use other BP target in intensive BP target group. The pooled OR of mortality and unfavorable outcome after ICH in intensive BP control group comparing with less intensive BP targets group were 0.99 (95% CI 0.81 to 1.23) and 0.90 (95% CI 0.78 to 1.03) respectively. The pooled OR were 0.97 (95% CI 0.80 to 1.18) for neurological deterioration and 0.83 (95% CI 0.61 to 1.11) for hematoma expansion. There is no difference in other adverse events between two groups. Acute lowering of SBP to 140 mmHg is probably beneficial for functional outcome in patients with ICH, but the evidence is still insufficient. Further large multicenter studies are required to enhance the evidence to guide the BP lowering target following ICH.

Intensive and Standard Blood Pressure Targets in Patients With Type 2 Diabetes Mellitus

BACKGROUND Treatment of hypertension in patients with diabetes mellitus (DM) has been shown to improve cardiovascular outcomes; however, the value of intensive blood pressure (BP) targets remains uncertain. We sought to determine the effectiveness and safety of treating BP to intensive targets (upper limit of 130 mm Hg systolic and 80 mm Hg diastolic) compared with standard targets (upper limit of 140-160 mm Hg systolic and 85-100 mm Hg diastolic) in patients with type 2 DM. METHODS Using electronic databases, bibliographies, and clinical trial registries, we conducted a systematic review and meta-analysis to identify randomized trials enrolling adults diagnosed as having type 2 DM and comparing prespecified BP targets. Data on study characteristics, risk for bias, and outcomes were collected. Random-effects models were used to pool relative risks and risk differences for mortality, myocardial infarction, and stroke. RESULTS The use of intensive BP targets was not associated with a significant decrease in the risk for mortality (relative risk difference, 0.76; 95% CI, 0.55-1.05) or myocardial infarction (relative risk difference, 0.93; 95% CI, 0.80-1.08) but was associated with a decrease in the risk for stroke (relative risk, 0.65; 95% CI, 0.48-0.86). The pooled analysis of risk differences associated with the use of intensive BP targets demonstrated a small absolute decrease in the risk for stroke (absolute risk difference, -0.01; 95% CI, -0.02 to -0.00) but no statistically significant difference in the risk for mortality or myocardial infarction. CONCLUSION Although the use of intensive compared with standard BP targets in patients with type 2 DM is associated with a small reduction in the risk for stroke, evidence does not show that intensive targets reduce the risk for mortality or myocardial infarction.

Protocol for Past BP: a randomised controlled trial of different blood pressure targets for people with a history of stroke of transient ischaemic attack (TIA) in primary care

BackgroundBlood pressure (BP) lowering in people who have had a stroke or transient ischaemic attack (TIA) leads to reduced risk of further stroke. However, it is not clear what the target BP should be, since intensification of therapy may lead to additional adverse effects. PAST BP will determine whether more intensive BP targets can be achieved in a primary care setting, and whether more intensive therapy is associated with adverse effects on quality of life.Methods/DesignThis is a randomised controlled trial (RCT) in patients with a past history of stroke or TIA. Patients will be randomised to two groups and will either have their blood pressure (BP) lowered intensively to a target of 130 mmHg systolic, (or by 10 mmHg if the baseline systolic pressure is between 125 and 140 mmHg) compared to a standard group where the BP will be reduced to a target of 140 mmHg systolic. Patients will be managed by their practice at 1-3 month intervals depending on level of BP and followed-up by the research team at six monthly intervals for 12 months.610 patients will be recruited from approximately 50 general practices. The following exclusion criteria will be applied: systolic BP <125 mmHg at baseline, 3 or more anti-hypertensive agents, orthostatic hypotension, diabetes mellitus with microalbuminuria or other condition requiring a lower treatment target or terminal illness.The primary outcome will be change in systolic BP over twelve months. Secondary outcomes include quality of life, adverse events and cardiovascular events.In-depth interviews with 30 patients and 20 health care practitioners will be undertaken to investigate patient and healthcare professionals understanding and views of BP management.DiscussionThe results of this trial will inform whether intensive blood pressure targets can be achieved in people who have had a stroke or TIA in primary care, and help determine whether or not further research is required before recommending such targets for this population.Trial RegistrationISRCTN29062286