Long-term blood pressure control is the cornerstone of secondary prevention for patients with intracerebral haemorrhage. Yet achieving sustained blood pressure targets in routine practice remains difficult because of therapeutic inertia and poor adherence. TRIDENT sought to determine if a fixed low-dose triple combination pill improves outcomes.
In this multinational, double-blind trial, 1,670 clinically stable patients with previous ICH and systolic blood pressure between 130 and 160 mmHg were randomised to receive either a once-daily triple pill (telmisartan 20 mg, amlodipine 2.5 mg, and indapamide 1.25 mg) or matching placebo. After a median follow-up of 2.5 years, recurrent stroke occurred in 4.6% of patients receiving the triple pill versus 7.4% in the placebo group (HR 0.61, 95% CI 0.41–0.92). Major cardiovascular events were also reduced (6.% in triple pill group vs. 9.8% in the placebo group; P=0.04)., while mean systolic blood pressure was 11 mmHg lower in the intervention arm (127 vs. 138 mmHg).
The findings reinforce a well-established principle: intensive blood pressure reduction saves brains. More importantly, TRIDENT demonstrates that simplifying treatment through a fixed-dose combination can translate this principle into meaningful clinical benefit. Although a 2-week run-in phase excluded patients unable to tolerate the regimen and treatment discontinuation due to adverse events, which was more frequent with the triple pill, the overall safety profile remained acceptable (serious adverse events occurred in 23.2% of the patients in the triple-pill group vs. 26.0% in the placebo group). Early discontinuation of the trial regimen occurred in 13.6% and 6.0%, respectively.