In patients with low baseline diastolic blood pressure and prior stroke, intensive systolic control did not seem to elevate the risk of stroke.

• Guidelines advocate lowering systolic blood pressure below 130 mm Hg, regardless of previous strokes.

• Researchers performed a secondary analysis of the Secondary Prevention of Small Subcortical Strokes trial that randomized individuals with a history of subcortical strokes to an intensive (<130 mm Hg; N=1,519) or standard (130–149 mm Hg; N=1,501) systolic targets.

• Mean baseline systolic and diastolic blood pressures were noted to be 143±19 and 78±11 mm Hg, respectively.

• Within each baseline diastolic blood pressure tertile, the achieved diastolic was shown to be lower in the intensive vs standard arm.

• Over 10 889 years of follow-up, 275 stroke events occurred.

• In an observational spline regression model, an elevated risk of stroke was demonstrated in relation to lower baseline diastolic blood pressure.

• Hazard ratios associating blood pressure intervention with stroke risk in the lowest (hazard ratio, 0.78) and the highest (hazard ratio, 0.80) baseline diastolic tertiles were identified to be similar.

• Similar outcomes were obtained for the cardiovascular composite.