One Pill To Rule Them All: The TRIDENT Trial and Stroke Prevention🧙‍♂️

You Shall Not Pass … 130 mmHg: Antihypertensives Vs Strokes

In the long war waged against hypertension-induced strokes, our weapons have been… underwhelming.

Lifestyle advice gets ignored.
Dossette boxes start to resemble a pack of Smarties.
Sphygs are inflated just once a year. (If only we could say the same about our wages)

All the while, BP slowly creeps back up. And with it, the risk of a serious brain bleed🩸

But what if we took a leaf out of Tolkien's book and crafted one pill to rule them all?

The TRIDENT trial, published in this week, did just that.

This new drug fellowship comprises 3 hypertension classics:

ARB + CCB + thiazide-like diuretic → all forged into a single once-daily tablet💊

I know what you’re thinking.
It’s too simple to work, right?🧌

But just Gimli a minute to explain the trial, it’s actually pretty cool stuff.

1,670 patients with prior intracerebral haemorrhage (and systolic BP 130-160 mmHg) were randomised to either:

The One Pill™ (telmisartan 20mg + amlodipine 2.5mg + indapamide 1.25mg OD), or

Matching placebo

Participants were then followed up every 6 months for up to 6 years.

The main outcome of interest? Recurrent stroke rate.

And here’s the verdict:

Recurrent stroke occurred in 4.6% (triple pill) vs 7.4% (placebo)
→ That’s a 39% relative risk reduction (HR 0.61, 95% CI 0.41-0.92, p=0.02)

Not just that, BP control at 6 months (i.e., systolic <130 mmHg) was achieved in 49.9% (triple pill) vs 26.4% (placebo) - nearly double!

AND Major cardiovascular events were reduced (6.6% vs 9.8%; HR 0.67, p=0.04).

Cumulative Incidence of First Recurrent Stroke (Primary Outcome)

The promise of success from The One Pill™ is strong.

After all, TRIDENT was a multinational, double-blind, placebo-controlled RCT across 12 countries, with demographics reflecting global ICH (intracerebral haemorrhage) populations.

But let's not get too precious about it yet:

Not everyone made it into the fellowship - a ‘run-in phase’ filtered out around a quarter of patients who couldn’t tolerate the pill upfront.

And even for those who did, early rises in creatinine meant not everyone could continue

66.7% of patients were from the same country, limiting generalisability

And yet, the allure of the One Pill as a simpler way for both patients and docs to keep that BP down is undeniable.

So in the battle for Middle- Earth of-the-range-BP post-stroke, the future calls for more than the boring old NICE flowchart.

It’s time for a 3-in-1 nuke instead💊💥