Background Lowering blood pressure (BP) after stroke remains a challenge, even in the context of clinical trials. The Secondary Prevention of Small Subcortical Strokes (SPS3) BP protocol, BP management during the study, and achieved BPs are described here. methods Patients with recent symptomatic lacunar stroke were randomized to 1 of 2 levels of systolic BP (SBP) targets: lower: <130 mm Hg, or higher: 130-149 mm Hg. SBP management over the course of the trial was examined by race/ethnicity and other baseline conditions. results Mean SBP decreased for both groups from baseline to the last followup, from 142.4 to 126.7 mm Hg for the lower SBP target group and from 143.6 to 137.4 mm Hg for the higher SBP target group. At baseline, participants in both groups used an average of 1.7 ± 1.2 antihypertensive medications, which increased to a mean of 2.4 ± 1.4 (lower group) and 1.8 ± 1.4 (higher group) by the end-study visit. It took an average of 6 months for patients to reach their SBP target, sustained to the last follow- up. Black participants had the highest proportion of SBP =150 mm Hg at both study entry (40%) and end-study visit (17%), as compared with whites (9%) and Hispanics (11%). conclusions These results show that it is possible to safely lower BP even to a SBP goal <130 mm Hg in a variety of patients and settings, including private and academic centers in multiple countries. This provides further support for protocol-driven care in lowering BP and consequently reducing the burden of stroke. © American Journal of Hypertension, Ltd 2014.