The PROGRESS trial three years later: time for more action, less distraction

Since the publication of the results of the PROGRESS trial, there has been much comment in the BMJ and elsewhere.1 2 Most of this acknowledges the importance of the findings for the care of patients with cerebrovascular disease. These patients are at high risk of stroke recurrence, and before the trial was completed few interventions had been proved to reduce this risk. Aspirin was known to modestly reduce the risk of recurrence of ischaemic stroke, but no treatment had been shown to reduce the frequently catastrophic recurrence of cerebral haemorrhage. This situation was changed profoundly by the results of PROGRESS, which showed that a simple blood pressure lowering regimen substantially reduced the risks of recurrent stroke,3 disability,4 and cardiac events5 across a broad range of blood pressure levels in patients with either ischaemic or haemorrhagic cerebrovascular disease. PROGRESS was conceived during an era in which many stroke specialists were concerned about possible risks of blood pressure lowering in patients with compromised cerebral circulation. While epidemiological evidence indicated that the lowest blood pressure levels were associated with the lowest risks of stroke recurrence,6 prevailing clinical opinion required us to allow individual doctors the discretion to determine the intensity of the blood pressure lowering regimen they provided to individual patients. …