BARCELONA, Spain — Intensive efforts to lower blood pressure (BP) to targets < 130/80 mm Hg in the first couple of days after a transient ischemic attack (TIA) or minor stroke were associated with a large reduction in recurrent stroke.
The prospective, observational COMMIT study evaluated a new policy encouraging intensive BP lowering in the first days after TIA or minor stroke, using home monitoring reviewed remotely by clinicians in a TIA or stroke clinic.
Results showed that this approach lowered systolic BP by up to 15 mm Hg, which was associated with about a 40% reduction in recurrent ischemic stroke and a 50% reduction in intracerebral hemorrhage over a 5-year follow-up.
“These results show that aggressive lowering of blood pressure in the very early phase immediately after a TIA or minor stroke is safe, effective, and feasible,” study investigator Iain McGurgan, MD, Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, England, told Medscape Medical News.
BP reduction should be initiated at the same time as antiplatelet therapy in the acute care of patients with TIA or minor stroke, McGurgan added.
He noted that although clinicians are quick to start antiplatelet therapy, they are often slower to initiate BP treatment, despite the need for equally aggressive management of all risk factors in the acute phase.
“Our message is to start antihypertensives early, intensify early, and control blood pressure well for patients with minor stroke and TIA,” he said.
The study findings were presented on October 24 at the 17th World Stroke Congress (WSC) 2025.
Rethinking BP Management
It is well known that in major stroke, immediate BP lowering is not beneficial and can even be harmful, but the situation in minor stroke and TIA has been uncertain, said McGurgan.
Current guidelines offer conflicting guidance. Some extrapolate from data related to major stroke and recommend caution with early BP lowering after a TIA or minor stroke, while others draw from secondary prevention trials and support early treatment. However, those trials generally enrolled patients later, leaving little evidence on optimal BP management in the immediate post-TIA or minor stroke period.
McGurgan noted that in a major stroke, there is concern that lowering BP in the acute period could decrease blood flow to an already compromised area of the brain.
“The ischemic area requires maximum perfusion, and we think the elevated blood pressure seen after ischemic stroke could be a compensatory mechanism to increase blood flow to the area of the brain that’s been damaged. But in minor stroke/TIA, there is very little or no brain ischemia, so concerns about reduced perfusion should not be an issue,” he noted.
However, he added that the residual risk for recurrent stroke after a TIA or minor stroke is still far too high, and the risk is highest in the first few weeks after the initial event.
“We are not being aggressive enough in lowering blood pressure in the secondary prevention setting. We know blood pressure needs to be well controlled in the long term after minor stroke/TIA, but there is a great deal of therapeutic inertia in this area.”
McGurgan explained that while BP management for major stroke is typically addressed at hospital discharge, patients with minor stroke or TIA are often seen in rapid-access clinics rather than admitted.
Such patients typically receive antiplatelet therapy, but BP is not managed as aggressively. They are often advised to follow up with their primary care physician to discuss secondary prevention, including BP control — a process that can take several weeks.
Substantial Reduction in Recurrence
The COMMIT study is part of the OXVASC population study, in which all patients with TIA or minor stroke (National Institutes of Health Stroke Scale, ≤ 4) in Oxfordshire, England, receive ongoing care through a dedicated TIA clinic. This model allows researchers to compare outcomes from planned sequential policy changes.
In 2008, the clinic introduced a new policy in which, in addition to giving immediate antiplatelet therapy to patients with TIA or minor stroke, efforts were made to intensively lower BP to < 130/80 mm Hg.
This approach involved patients self-monitoring BP at home, with telemetric transmission of readings reviewed daily by physicians for 1-3 months.
Patients measured their BP three times daily, taking three readings each time, for a total of nine readings per day. Physicians reviewed the results in real time and adjusted antihypertensive therapy as needed, sending prescriptions directly to the patient’s pharmacy.
The observational study evaluated outcomes in patients treated before and after implementation of the intervention. The comparison involved 2135 patients advised to initiate BP-lowering therapy as indicated with follow-up in primary care and 1548 patients recruited after 2008 who participated in the telemetric monitoring program.
Those in the intervention arm were enrolled within about 48 hours of TIA or stroke — substantially earlier than in prior secondary prevention studies, McGurgan said.
Across the entire study population, systolic BP fell by about 10 mm Hg after the intervention was introduced, regardless of participation. Mean clinic BP at first follow-up declined from 137/75 mm Hg before the policy changed to 127/72 mm Hg afterward. In patients who participated in the intervention, BP was reduced to 122/70 mm Hg.
Results showed substantial 5-year reductions in both ischemic and hemorrhagic stroke among patients enrolled in the intervention compared with those managed prior to its implementation.
Recurrent ischemic stroke was reduced by nearly 40% (adjusted HR, 0.62; 95% CI, 0.50-0.77), and intracerebral hemorrhage by more than 50% (adjusted HR, 0.48; 95% CI, 0.25-0.91).
McGurgan noted that the findings were in a population with stable temporal trends and generally well-managed treatment. Analyses were adjusted for baseline risk factors, age, and sex.
Reassuring Safety Data
Regarding safety, 2%-3% of patients experienced hypotension during monitoring that necessitated dose reduction. McGurgan noted that this low rate suggests the approach is safe even without universal use of home telemetric monitoring.
“These results suggest that we need to be aggressively treating these patients immediately after their TIA/minor stroke to a target of below 130 mm Hg systolic,” he said.
McGurgan noted that using a telemetric approach is an effective way to implement this policy and helps ensure safety. However, he added that the safety data were highly reassuring, suggesting that simply asking patients to monitor their BP regularly at home would likely be sufficient.
The COMMIT investigators attributed the study’s success to the centralized management of patients through the TIA clinic. McGurgan emphasized that rapid intervention is essential, noting that “it is vitally important in this early high-risk phase that these patients have their risk of recurrent stroke reduced as quickly as possible, which means getting them on all the right treatments straight away.”
He added that the first few days after a TIA or stroke carry the greatest risk for recurrence.
“This is when you get the most bang for your buck” — and that a centralized approach helps ensure timely treatment.
Need for Better Poststroke Care
Commenting on the study for Medscape Medical News, Craig Anderson, MD, of The George Institute for Global Health, Sydney, Australia, praised the findings.
Anderson — who led the TRIDENT trial, which was also presented at the WSC and showed substantial reductions in recurrent stroke risk among patients with intracerebral hemorrhage treated with intensive BP lowering — said that the COMMIT study complements these results and emphasizes “the importance of early and sustained blood pressure control after acute stroke or TIA, including intracerebral hemorrhage.”
He added that COMMIT also supports other studies showing that patient-empowered home BP monitoring is an effective strategy.
“Of course, one has to be cautious of causal inferences from the observational nature of the COMMIT study and also generalizability to other populations and healthcare settings with different resourcing and sociodemographic characteristics,” he noted.
But he added that, in general, the outpatient organization for diagnostic assessment, follow-up review, and risk factor management of patients is poorly organized across the world.
“COMMIT, TRIDENT, and accumulating other studies are providing the evidence to support the need to change this aspect of stroke services to provide optimum care for patients,” said Anderson.
The COMMIT and OXVASC studies were funded by grants from the National Institute for Health Research, Oxford Biomedical Research Centre, Wellcome Trust, and The Wolfson Foundation. McGurgan reported receiving funding from the Association of British Neurologists, Stroke Association, and Sobell Foundation.