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Stroke is a leading cause of disability among hypertensive adults, with notable sex differences in risk and outcomes. Neutrophil percentage-to-albumin ratio (NPAR) is an easily obtainable composite index of systemic inflammation with prognostic value in cardiovascular disease, but its utility for primary stroke prevention in hypertension remains unclear. We therefore examined the association of NPAR with first stroke in hypertensive adults and tested for sex-specific effects. We analyzed 13 848 participants from the China Stroke Primary Prevention Trial. NPAR was calculated as the neutrophil percentage (%) × 100/albumin (g/dL). Cox proportional hazards models evaluated the association between NPAR and first stroke, and subgroup analyses assessed sex-specific effects. During a median follow-up of 4.5 years, 371 participants (2.7%) experienced stroke. The risk of stroke was significantly higher in Q2, Q3, and Q4 than in Q1 (HR 1.76, 95% CI 1.31-2.36, p < 0.001 [Q2], HR 1.54, 95% CI 1.14-2.08, p = 0.005 [Q3], and HR 1.57, 95% CI 1.17-2.12, p = 0.003 [Q4] in the adjusted model). The result remained consistent when the Q2 to Q4 groups were combined and compared with the Q1 group. Subgroup analysis revealed a significant sex difference, with higher NPAR associated with increased stroke risk in women but not in men (p = 0.035). These findings suggest that higher NPAR independently predicts stroke risk in patients with hypertension, with a substantially stronger association in women, and highlight sex-specific inflammatory mechanisms and the potential of NPAR as a biomarker for female-focused prevention strategies.