Glyceryl Trinitrate for Acute Intracerebral Hemorrhage

Dec 17, 2015
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Authors:
Krishnan K, Scutt P, Woodhouse L, et al.
Citation:
Glyceryl Trinitrate for Acute Intracerebral Hemorrhage: Results From the Efficacy of Nitric Oxide in Stroke (ENOS) Trial, a Subgroup Analysis. Stroke 2015;Dec 8:[Epub ahead of print].
Summary By:
Geoffrey D. Barnes, MD, MSc, FACC

Study Questions:

What are the effects of transdermal glyceral trinitrate (a nitric oxide donor) for blood pressure lowering in patients with acute intracerebral hemorrhage (ICH)?

Methods:

The authors performed a prespecified subgroup analysis of the randomized ENOS (Efficacy of Nitric Oxide in Stroke) trial, where use of glyceral trinitrate was found to lower blood pressure, but not impact functional outcome. The effect on the modified Rankin Scale at 90 days was assessed in the 629 patients with ICH presenting within 48 hours and an elevated systolic blood pressure (>140 mm Hg).

Results:

Mean blood pressure decreased from a mean 172/93 mm Hg at baseline more in the glyceral trinitrate group than the control group (-7.5/-4.2 mm Hg, p ≤ 0.05) on hospital day 1. No difference in the modified Rankin Scale was observed between the treatment and control groups (adjusted odds ratio [OR], 1.04; 95% confidence interval [CI], 0.78-1.37). In the subgroup of patients randomized within 6 hours, use of glyceral trinitrate was associated with improved modified Rankin Scale (OR, 0.22; 95% CI, 0.07-0.69).

Conclusions:

The authors concluded that in patients with acute ICH presenting within 48 hours, use of glyceral trinitrate significantly lowered blood pressure, but did not improve functional status. There may be an impact on functional status for patients who presented within 6 hours and were treated with glyceral trinitrate.

Perspective:

Acute ICH is devastating form of acute stroke for which contemporary treatment strategies are often inadequate to prevent significant morbidity. Glyceryl trinitrate was hypothesized to lower blood pressure without negatively affecting cerebral blood flow. While this medication achieved its blood pressure lowering target, clinic outcomes were only improved in patients who presented rapidly (within 6 hours). Additionally, there was no testing of a ‘dose response’ to see if a higher dose of glyceral trinitrate may have achieved further blood pressure reductions and/or improved clinical outcomes. Future studies may address these issues.

Keywords: Blood Pressure, Blood Pressure Determination, Cerebral Hemorrhage, Hypotension, Nitric Oxide, Nitroglycerin, Stroke, Vascular Diseases


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