PINGS
(2026)Objective
To test whether a nurse-led, mHealth-based bundled intervention (home BP self-monitoring, medication-reminder phone alarms, weekly audio health education) improves blood pressure control among recent stroke survivors with uncontrolled hypertension in Ghana compared with usual care.
Study Summary
• BP <140/90 mm Hg at 12 months: 56% vs 38% by ITT, p<0.001; relative risk of SBP control 1.57 (95% CI 1.33-1.86)
• No reduction in major adverse cardiovascular events (HR 0.79, 95% CI 0.35-1.79) or all-cause mortality (5.7% vs 5.5%); serious AEs 11.1% vs 7.0% (p=0.12)
Intervention
Phone-based intervention under nurse guidance (PINGS): home BP monitoring with nurse-navigator follow-up for abnormal readings, medication-reminder phone alarms, and weekly local-dialect audio health-education messages for 12 months, on top of usual stroke care.
Inclusion Criteria
Adults ≥18 with CT-confirmed ischemic or intracerebral hemorrhagic stroke within 1 month (or 8-QVSFS positive when neuroimaging unavailable) and uncontrolled BP ≥140/90 mm Hg at screening, owning a basic phone capable of receiving text/audio messages.
Study Design
Arms: PINGS intervention plus usual care vs usual care alone (with non-medical SMS lifestyle messages as attention control).
Patients per Arm: PINGS 244; Usual care 256 (total 500 randomized; 410 completed 12 months)
Outcome
• Mean SBP reduction from baseline at 12 mo: -20 vs -14 mm Hg; between-group -5.9 mm Hg (95% CI -11.0 to -1.1, p=0.016)
• Secondary MACE adjusted HR 0.79 (95% CI 0.35-1.79); serious AEs 11.1% vs 7.0% (p=0.12); deaths 5.7% vs 5.5%; mRS shift OR 1.12 (95% CI 0.79-1.57)
• Effect consistent across age, sex, stroke type, education, income, baseline SBP, and across primary vs tertiary hospitals
Clinical Question
In recent stroke survivors with uncontrolled hypertension in a resource-limited African setting, does a nurse-led, phone-based, mHealth bundled intervention (home BP self-monitoring with nurse navigation, medication-reminder phone alarms, weekly local-dialect audio health education) improve blood pressure control at 12 months compared with usual care?
Bottom Line
A pragmatic, low-tech, nurse-navigated, phone-based mHealth bundle improved 12-month systolic BP control after stroke in Ghana (67% vs 43% achieving SBP <140 mm Hg, between-group difference 24%, p<0.001), without translating into significant reductions in major adverse cardiovascular events or mortality at one year.
Major Points
- Phase III, multicenter, open-label, blinded-endpoint RCT across 10 hospitals in Ghana (3 tertiary, 2 secondary/district, 5 primary), enrolling 500 recent stroke survivors with uncontrolled BP ≥140/90 mm Hg.
- Intervention combined weekly home BP self-monitoring with nurse-navigator follow-up for out-of-range readings, daily phone-alarm medication reminders, and once-weekly 1-2 minute audio health-education messages in local Ghanaian dialects for 48 weeks.
- Primary outcome (proportion with SBP <140 mm Hg at month 12) markedly favored PINGS: 67% vs 43% (Δ 24%, 95% CI 15-33%, p<0.001 by ITT; 71% vs 45% per-protocol, p<0.001).
- Mean systolic BP fall from baseline at 12 months was 20 vs 14 mm Hg (between-group difference -5.9 mm Hg, 95% CI -11.0 to -1.1, p=0.016).
- BP <140/90 mm Hg at 12 months: 56% vs 38% by ITT (60% vs 41% per-protocol), p<0.001.
- No significant differences in MACE (adjusted HR 0.79, 95% CI 0.35-1.79), all-cause mortality (5.7% vs 5.5%), serious adverse events (11.1% vs 7.0%, p=0.12), or modified Rankin Scale shift at 12 months (OR 1.12, 95% CI 0.79-1.57).
- Mediator analyses showed no detectable difference in medication adherence (medication possession ratio, Hill-Bone), hypertension self-care, health literacy, or quality of life; total antihypertensive treatment intensity score was modestly higher in PINGS over follow-up.
- Effect of intervention preserved across subgroups including stroke type, sex, age, education, income (effect actually larger in lower-income participants), baseline SBP, and across primary/district vs tertiary hospital sites — supporting scalability in resource-limited settings.
Study Design
- Study Type
- Randomized Controlled Trial
- Randomization
- Yes
- Blinding
- Open-label with blinded outcome assessment (PROBE design); office BP measured by trained assessors blinded to allocation; independent panel adjudicated MACE.
- Sample Size
- 500
- Follow-up
- 12 months (last follow-up 5 April 2024)
- Centers
- 10
- Countries
- Ghana
Primary Outcome
Definition: Proportion of participants achieving systolic BP <140 mm Hg at month 12 (intention-to-treat)
| Control | Intervention | HR/OR | P-value |
|---|---|---|---|
| 43% (109/256) | 67% (163/244) | - (1.33-1.86) | <0.001 |
Limitations & Criticisms
- Open-label design — patients, clinicians, and on-site research staff were unblinded; only outcome assessors and MACE adjudicators were blinded (PROBE design).
- 12.3% of PINGS and 12.5% of UC participants did not complete the study; missing primary outcomes imputed by last observation carried forward, which can bias toward earlier (less controlled) measurements.
- Clinic-measured (not ambulatory) BP at screening may have excluded patients with masked hypertension and let in some with white-coat BP elevation.
- Sample size (n=500) and 12-month follow-up underpowered to detect differences in recurrent stroke, MACE, or mortality.
- Stroke-type and diabetes imbalance at randomization required statistical adjustment.
- Pre-specified mediators (medication adherence, self-care, health literacy, quality of life) did not differ, leaving the mechanism of BP improvement only partially explained; total antihypertensive intensity score was modestly higher in PINGS at baseline as well as during follow-up.
- Generalizability beyond Ghana to other low- and middle-income settings unproven; future hybrid implementation studies with longer follow-up needed.
Citation
Circulation. 2026 Jun 16. doi:10.1161/CIRCULATIONAHA.125.077424