Intracranial hemorrhage is a common medical emergency in ER secondary to hypertension. So it is important to control blood pressure as early as possible. The target SBP in ICH is area of concern, now let us look at the recent evidences.
Recent Evidence
INTERACT 2 RCT (NEJM.2013) was done to assess wether rapid lowering of elevated blood pressure would improve the outcomes in patients with ICH. 2839 patients were randomly assigned to intensive treatment group (SBP <140 mmHg in 1 hour) or guideline recommended treatment (SBP <180 mmHg). The study found that In patients with intracerebral hemorrhage, intensive lowering of blood pressure
did not result in a significant reduction in the rate of the primary outcome of death or severe disability (OR=0.87; 95%CI, 0.75 to 1; p = 0.06) . An ordinal analysis of modified Rankin scores indicated improved functional outcomes with intensive lowering of blood pressure (OR=0.87; 95%CI, 0.77 to 1; p = 0.04) .
ATACH-2 RCT (NEJM.2016) randomly assigned patients with IC Bleed ( Volume <60cm3 , GCS > or =5) either to intensive treatment group ( 110 -139 mmHg) n= 500 or standard group ( 140 -179 mmHg), n=500. Patients were treated with IV Nicardipine within 4.5 hours after symptom onset. The study found that intensive treatment to achieve a target target systolic blood pressure of 110 to 139 mm Hg did not result in a lower rate of death or disability (38.7%) than standard reduction to a target of 140 to 179 mm Hg(37.7%) RR : 1.04, 95% CI 0.85 -1.27.
INTERACT 3 (Lancet.2023) is a multicentric, randomised, blinded endpoint study done to asses wether a goal directed care bundle incorporating early intensive bp lowering (SBP <140mmHg) and management algorithms for hyperglycemia, pyrexia and abnormal anticoagulation, implemented in hospital setting could improve outcomes for patients with acute spontaneous ICH.The likelihood of a poor functional outcome was lower in the care bundle group, n=3221 (common odds ratio 0·86; 95% CI 0·76–0·97; p=0·015). Patients in the care bundle group had fewer serious adverse events than those in the usual care group (16·0% vs 20·1%; p=0·0098).
Current Recommendation
- AHA/ASA recommends to target a SBP of 140mmHg with goal of maintaing a range of 130 -150 mmHg in mild to moderate ICH with SBP of 150 -220 mmHg at presentation.
- AHA/ASA states that safety and efficacy of intensive BP control in severe ICH has not be well established.
Post HOC analysis of ATACH-2 Trial has shown that intensive BP targets <130 mmHg in large ICH , severe IVH requiring EVD was associated with increased mortality and poor outcomes due to decreased CPP < 60mmHG. Study has also shown that participants with SBP >220 mmHG reported higher rates of neurological deterioration at 24 hours and renal adverse events until 7 days in intensive treatment group.
Reference
- Anderson CS, Heeley E, Huang Y, Wang J, Stapf C, Delcourt C, Lindley R, Robinson T, Lavados P, Neal B, Hata J, Arima H, Parsons M, Li Y, Wang J, Heritier S, Li Q, Woodward M, Simes RJ, Davis SM, Chalmers J; INTERACT2 Investigators. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013 Jun 20;368(25):2355-65. doi: 10.1056/NEJMoa1214609. Epub 2013 May 29. PMID: 23713578.
- Ma L, Hu X, Song L, Chen X, Ouyang M, Billot L, Li Q, Malavera A, Li X, Muñoz-Venturelli P, de Silva A, Thang NH, Wahab KW, Pandian JD, Wasay M, Pontes-Neto OM, Abanto C, Arauz A, Shi H, Tang G, Zhu S, She X, Liu L, Sakamoto Y, You S, Han Q, Crutzen B, Cheung E, Li Y, Wang X, Chen C, Liu F, Zhao Y, Li H, Liu Y, Jiang Y, Chen L, Wu B, Liu M, Xu J, You C, Anderson CS; INTERACT3 Investigators. The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trial. Lancet. 2023 Jul 1;402(10395):27-40. doi: 10.1016/S0140-6736(23)00806-1. Epub 2023 May 25. Erratum in: Lancet. 2023 Jul 15;402(10397):184. doi: 10.1016/S0140-6736(23)01420-4. PMID: 37245517; PMCID: PMC10401723.
- Qureshi AI, Palesch YY, Barsan WG, Hanley DF, Hsu CY, Martin RL, Moy CS, Silbergleit R, Stein T, Suarez JI, Toyoda K, Wang Y, Yamamoto H, Yoon BW; ATACH-2 Trial Investigators and the Neurological Emergency Treatment Trials Network. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. N Engl J Med. 2016 Sep 15;375(11):1033-43. doi: 10.1056/NEJMoa1603460. Epub 2016 Jun 8. PMID: 27276234; PMCID: PMC5345109.
- AHA/ASA Guideline for the management of spontaneous ICH. 2022
