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Degree of blood pressure reduction and recurrent stroke: the PROGRESS trial
  1. Hisatomi Arima1,
  2. Craig Anderson1,
  3. Teruo Omae2,
  4. Mark Woodward1,
  5. Stephen MacMahon1,3,
  6. Giuseppe Mancia4,
  7. Marie-Germaine Bousser5,
  8. Christophe Tzourio6,7,
  9. Stephen Harrap8,
  10. Lisheng Liu9,
  11. Bruce Neal1,
  12. John Chalmers1
  13. for the PROGRESS Collaborative Group
  1. 1The George Institute for Global Health, University of Sydney, Sydney, New South Wales, Australia
  2. 2National Cerebral and Cardiovascular Center, Suita, Japan
  3. 3George Centre of Healthcare Innovation, University of Oxford, Oxford, UK
  4. 4Università Milano-Bicocca, Ospedale San Gerardo, Milan, Italy
  5. 5The Department of Neurology, Hôpital Lariboisière, Paris, France
  6. 6INSERM U897, Bordeaux, France
  7. 7University of Bordeaux, Bordeaux, France
  8. 8Department of Physiology, University of Melbourne, Melbourne, Australia
  9. 9National Centre for Cardiovascular Diseases, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
  1. Correspondence to Professor John Chalmers, The George Institute for Global Health, PO Box M201, Missenden Road, Sydney, NSW 2050 Australia; chalmers{at}


Objective There is ongoing controversy regarding a ‘J-curve’ phenomenon such that low and high blood pressure (BP) levels are associated with increased risks of recurrent stroke. We aimed to determine whether large treatment-related BP reductions are associated with increased risks of recurrent stroke.

Design Data are from the PROGRESS trial, where 6105 patients with cerebrovascular disease were randomly assigned to either active treatment (perindopril±indapamide) or placebo(s). There were no BP criteria for entry. BP was measured at every visit, and participant groups defined by reduction in systolic BP (SBP) from baseline were used for the analyses. Outcome was recurrent stroke.

Results During a mean follow-up of 3.9 years, 727 recurrent strokes were observed. There were clear associations between the magnitude of SBP reduction and the risk of recurrent stroke. After adjustment for cardiovascular risk factors and randomised treatment, annual incidence was 2.08%, 2.10%, 2.31% and 2.96% for participant groups defined by SBP reductions of ≥20, 10–19, 0–9 and <0 mm Hg, respectively (p=0.0006 for trend).

Conclusions The present analysis provided no evidence of an increase in recurrent stroke associated with larger reductions in SBP produced by treatment among patients with cerebrovascular disease.

  • Stroke
  • Epidemiology

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