Blood Pressure Control and Risk of Recurrent Intracerebral Hemorrhage

Study Questions:

What is the association between blood pressure (BP) after index intracerebral hemorrhage (ICH) and risk of recurrent ICH?

Methods:

This was a single-site, tertiary care referral center observational study of 1,145 of 2,197 consecutive patients with ICH presenting from July 1994 to December 2013. A total of 1,145 patients with ICH survived at least 90 days and were followed up through December 2013 (median follow-up of 36.8 months [minimum, 9.8 months]). Blood pressure measurements at 3, 6, 9, and 12 months, and every 6 months thereafter, were obtained from medical personnel (inpatient hospital or outpatient clinic medical or nursing staff) or via patient self-report. Exposure was characterized in three ways: 1) recorded systolic and diastolic measurements; 2) classification as adequate or inadequate BP control based on American Heart Association/American Stroke Association recommendations; and 3) stage of hypertension based on Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 7 criteria. The main outcome measure was recurrent ICH and its location within the brain (lobar vs. nonlobar).

Results:

There were 102 recurrent ICH events among 505 survivors of lobar ICH, and 44 recurrent ICH events among 640 survivors of nonlobar ICH. During follow-up, adequate BP control was achieved on at least one measurement by 625 patients (54.6% of total [range, 49.2%-58.7%]) and consistently (i.e., at all available time points) by 495 patients (43.2% of total [range, 34.5%-51.0%]). The event rate for lobar ICH was 84 per 1,000 person-years among patients with inadequate BP control compared with 49 per 1,000 person-years among patients with adequate BP control. For nonlobar ICH, the event rate was 52 per 1,000 person-years with inadequate BP control compared with 27 per 1,000 person-years for patients with adequate BP control. In analyses modeling BP control as a time-varying variable, inadequate BP control was associated with higher risk of recurrence of both lobar ICH (hazard ratio [HR], 3.53; 95% confidence interval [CI], 1.65-7.54) and nonlobar ICH (HR, 4.23; 95% CI, 1.02-17.52). Systolic BP during follow-up was associated with increased risk of both lobar ICH recurrence (HR, 1.33 per 10 mm Hg increase; 95% CI, 1.02-1.76) and nonlobar ICH recurrence (HR, 1.54; 95% CI, 1.03-2.30). Diastolic BP was associated with increased risk of nonlobar ICH recurrence (HR, 1.21 per 10 mm Hg increase; 95% CI, 1.01-1.47), but not with lobar ICH recurrence (HR, 1.36; 95% CI, 0.90-2.10).

Conclusions:

The authors concluded that inadequate BP control during follow-up was associated with higher risk of both lobar and nonlobar ICH recurrence.

Perspective:

In this observational single-center cohort study of ICH survivors, reported BP measurements suggesting inadequate BP control during follow-up were associated with higher risk of both lobar and nonlobar ICH recurrence. These results confirm that ICH survivors are at high risk for recurrence and support the hypothesis that aggressive blood pressure control may reduce this risk substantially. Although clinical trials of aggressive versus conservative BP management in ICH survivors should be performed, more proactive management of BP for ICH survivors according to existing or current guidelines would substantially reduce the risk of ICH recurrence and its associated toll in terms of mortality and disability.

Clinical Topics: Prevention, Hypertension

Keywords: Blood Pressure, Cerebral Hemorrhage, Hypertension, Outcome Assessment (Health Care), Primary Prevention, Risk, Stroke, Survivors, Vascular Diseases


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