From tackling blood clots to managing blood pressure (BP), three separate trials presented at AHA 2026 – REDUCE, OCEANIC-STROKE and OPTIMAL-STROKE – offer new insights into improving outcomes after stroke.

In the REDUCE trial, adding the diuretic medication spironolactone to post-stroke managed of adults with uncontrolled high BP resulted in lower average systolic BP at three months vs. usual post-stroke care.

The trial enrolled 160 adult stroke survivors with high BP from five U.S. medical centers, of whom the average age was 63 years, 38% were women and roughly 30% self-identified as Black adults and 16% as Hispanic adults. In contrast to prior trials assessing spironolactone, participants in the REDUCE trial were receiving only two antihypertensive medications at baseline.

Upon enrollment, participants tracked their BP at home using a digital monitor for three to five days and were then randomly assigned to receive daily spironolactone pills in addition to their regular medications, or usual post-stroke care. Results from home BP monitoring devices were reviewed at one, two, three and six months.

Overall findings found that patients in the spironolactone group had a home-measured systolic BP that was approximately 8 mm Hg lower on average than the standard care group at three months (~126 mm Hg vs. 133 mm Hg, respectively). Diastolic BP also improved at three months with spironolactone compared with standard post-stroke care.

Additionally, more than half of those receiving spironolactone had reached the guideline-recommended BP goal of 130/80 mm hg or less, compared with 30% assigned to usual care. Researchers also noted that the diuretic was well tolerated overall, with similar rates of serious side effects across both groups. Of note, the study was not designed to determine whether spironolactone lowers the risk of another stroke or heart attack, and larger, longer studies are needed to answer this question.

“We were surprised to see that BP dropped twice as much as we expected. In an exploratory analysis, the BP drop was larger in people who started this medication within three months after a stroke,” said Jordana B. Cohen, MD, in presenting the findings. “We hope these findings encourage health care professionals to consider adding spironolactone sooner. In addition, we hope the results illustrate the importance of routine home BP monitoring to reduce the increased cardiovascular disease risks associated with any level of high BP.”

Researchers involved with the OCEANIC-STROKE trial assessed FXIa inhibition with asundexian in patients with non-cardioembolic stroke or high-risk transient ischemic attack (TIA) based on baseline risk factors.

Mukul Sharma, MD, et al., categorized patients by non-laboratory Framingham Risk Score (FRS), and found asundexian reduced ischemic stroke with similar bleeding versus placebo across all FRS categories. No significant interaction between treatment and FRS risk categories for efficacy and safety outcomes was observed and there was no evidence that the effect of asundexian differed by baseline vascular risk, they said.

In the OPTIMAL-STROKE trial conducted at 30 sites in Brazil, researchers investigated whether intensive BP control targeting a systolic BP of 120 mm Hg or less in patients with elevated BP and previous ischemic stroke or TIA reduced the risk of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke or hospitalization for unstable angina or heart failure.

Nearly 4,500 patients (mean age 64 years and nearly 50% women) were assigned to either intensive BP treatment or standard treatment (systolic BP goal of 140 mm Hg or less).

The findings, simultaneously published in NEJM, found that over a median follow-up of nearly four years, the mean systolic BP was 122.0 mm Hg in the intensive-treatment group and 135.2 mm Hg in the standard-treatment group, with a between-group mean difference of 13.1 mm Hg. A primary outcome event occurred in 236 patients in the intensive group (10.9%) compared with 297 patients receiving standard care (13.5%).

In other findings, a sustained reduction of ≥50% in the estimated glomerular filtration rate or progression to end-stage renal disease was more common with intensive treatment vs. standard care, but the overall incidence of serious adverse events was similar across both groups. The increase in kidney-related events in the intensive treatment group highlights the importance of individualized treatment and careful monitoring, researchers said.

In presenting the findings, Gisele Sampaio Silva, MD, PhD, MSc, said the study “shows that for many people who have already experienced an ischemic stroke or TIA, aiming for a systolic BP below 120 mm Hg can provide additional cardiovascular protection compared with the conventional target of below 140 mm Hg.” But she cautioned that “achieving lower BP safely requires appropriate medical supervision and additional monitoring, particularly of kidney function.”

Clinical Topics: Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Vascular Medicine, Acute Heart Failure

Keywords: AHA Annual Scientific Sessions, AHA26, Blood Pressure, Ischemic Stroke, Kidney Failure, Chronic, Myocardial Infarction, Angina, Unstable, Heart Failure, Thrombosis, Kidney