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):

  1. Optimal blood pressure (BP) target in patients with ICH is controversial at this point.
  2. 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).
  3. 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.
  4. 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.
  5. 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.
  6. ATACH-II actually compared intensive versus ultra-intensive BP in ICH and not standard versus intensive therapy.
  7. 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.
  8. 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.
  9. Current trials have enrolled very few patients with large ICH to provide evidence-supported guidance.
  10. Additional studies are indicated to assess optimal BP levels in the subset of patients with large ICH.

Clinical Topics: Prevention

Keywords: Antihypertensive Agents, Blood Pressure, Blood Pressure Determination, Cerebral Hemorrhage, Intracranial Hemorrhages, Hypotension, Nitroprusside, Primary Prevention, Vascular Diseases

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