For the roughly one in four stroke survivors whose event was hemorrhagic rather than ischemic, secondary prevention remains a persistent clinical challenge. Blood pressure reduction is already a cornerstone of post-ICH management, yet the field has lacked the statistical power to answer more granular questions: which patients benefit most, how quickly benefits emerge, and whether effects differ across cardiovascular versus non-cardiovascular endpoints. A coordinated pooling effort may finally provide those answers.
The RECAP-ICH initiative is a pre-registered individual participant data (IPD) meta-analysis that will integrate raw patient-level data from four major randomized controlled trials — TRIDENT, ESPRIT, PROGRESS, and a fourth qualifying RCT — each contributing cohorts of at least 100 ICH patients receiving antihypertensive therapy for secondary prevention. By working with IPD rather than aggregate trial statistics, investigators can conduct subgroup analyses by baseline BP level, hemorrhage location, age, and comorbidity burden with substantially greater precision than conventional meta-analyses allow. The PRISMA-IPD framework governs the systematic review, and searches were conducted across multiple databases through January 2026.
The significance of this protocol lies in what pooled IPD can reveal that no single trial can. PROGRESS, published in 2001, established that perindopril-based regimens reduce recurrent stroke risk, but its ICH subgroup was underpowered for fine-grained inference. TRIDENT, a more recent intensive-lowering trial, offers contemporary treat-to-target data. Merging these datasets could clarify whether tighter systolic targets confer additional benefit in lobar versus deep ICH — a distinction that matters because lobar bleeds are more often amyloid-related, raising theoretical concern about over-aggressive pressure reduction. Key limitations include the inherent heterogeneity of trial designs, follow-up durations, and BP targets across contributing studies. This is a protocol paper, so no outcomes are yet reported — the analytical value will depend entirely on execution quality and data harmonization rigor. If successful, RECAP-ICH could reframe post-ICH hypertension guidelines with individual-level precision currently absent from the evidence base.