Blood Pressure Lowering in Intracerebral Hemorrhage
- Anderson CS, Selim MH, Molina CA, Qureshi AI.
- Intensive Blood Pressure Lowering in Intracerebral Hemorrhage. Stroke 2017;48:2034-2037.
The following are key points to remember about intensive blood pressure lowering in intracerebral hemorrhage (ICH):
- Optimal blood pressure (BP) target in patients with ICH is controversial at this point.
- This article is a debate about the seemingly contradictory results of the largest trials investigating intensive BP lowering after acute ICH—INTERACT2 (Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial 2) and ATACH-II (Antihypertensive Treatment for Acute Cerebral Hemorrhage II).
- The two trials randomized patients with acute spontaneous ICH to a systolic BP (SBP) target of <140 to <180 mm Hg; but unlike INTERACT2, which suggested that lowering SBP to a target of ≤140 mm Hg is safe and beneficial (albeit the benefit was modest and marginal), ATACH-II casted doubt on the safety and efficacy of intensive SBP lowering to <140 mm Hg.
- After INTERACT2, a new target SBP of ≤140 mm Hg was adopted, and this change in practice likely resulted in more aggressive lowering of SBP closer to 140 mm Hg.
- A closer look at the data from INTERACT2 and ATACH-II clearly shows that SBP during the first 24 hours was approximately 120s mm Hg in the intensive-treatment group and 140s mm Hg in the standard-treatment group in ATACH-II versus 140s to 150s mm Hg and 160s mm Hg, respectively, in INTERACT2.
- ATACH-II actually compared intensive versus ultra-intensive BP in ICH and not standard versus intensive therapy.
- Like INTERACT2, ATACH-II supported the safety of SBP lowering to 140 mm Hg. In addition, ATACH-II showed that more aggressive lowering of BP is not of added benefit and was harmful.
- Overall, these data appear to support the use of any antihypertensive agent, other than nitroprusside, to decrease SBP to 140 mm Hg, but not much lower, in acute ICH patients.
- Current trials have enrolled very few patients with large ICH to provide evidence-supported guidance.
- Additional studies are indicated to assess optimal BP levels in the subset of patients with large ICH.
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