Blood pressure management for stroke patients beyond the JSH 2025 guidelines

As scientific evidence on blood pressure reduction in patients with chronic stroke accumulates year by year, target blood pressure levels recommended in guidelines, both in Japan and internationally, have tended to become lower. In addition, with respect to antihypertensive strategies, the Japanese Society of Hypertension Guidelines for the Management of Elevated Blood Pressure and Hypertension 2025 (JSH2025) assign a higher level of recommendation to the angiotensin receptor-neprilysin inhibitor and mineralocorticoid receptor antagonist, in addition to the conventional first-line major drugs. In patients with resistant hypertension, renal denervation can be clinically used in Japan from 2026. However, the effect of stroke prevention in these newer drugs or renal denervation remains unclear and should be further elucidated. Recommendations for blood pressure management in acute-phase stroke, particularly ischemic stroke without receiving reperfusion therapy, remain unsettled, despite the fact that the validity of relatively strict blood pressure targets has been examined in multiple clinical trials to date.