Getting Low: Rapid Blood Pressure Lowering after Intracerebral Hemorrhage

Published - Written by Rena Xu

When a patient presents with signs of a stroke, time is of the essence.  But if the cause of the stroke turns out to be bleeding within the brain, how rapidly should the patient be treated?  Specifically, when it comes to high blood pressure — a common problem among these patients, and a predictor of outcome — does early, aggressive treatment make sense?

Traditional guidelines recommend starting treatment only if systolic blood pressure (SBP) exceeds 180 mmHg.  Recently, however, investigators have asked whether there is benefit to lowering SBP below 140 mmHg — and doing so quickly.  In this week’s NEJM, Anderson et al. present the findings of a multicenter, prospective, randomized trial comparing the two approaches.

The Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2) trial enrolled 2800 participants who had suffered a spontaneous intracerebral hemorrhage within the previous 6 hours and had an SBP elevated to between 150 and 220 mmHg.  Participants were randomized to receive either early intensive treatment — with the goal of achieving an SBP below 140 mmHg within 1 hour of randomization — or guideline-recommended treatment, meaning no treatment until SBP exceeded 180 mmHg, with no lower target SBP specified.  The outcome of interest was death or major disability, defined as a score of 3 to 6 on the modified Rankin scale (a score of 0 means no symptoms; 5 means severe disability; 6 means death).

The trial found no significant difference between the two groups in terms of how frequently a primary outcome event occurred: 52% of participants in the intensive treatment group had an event, as compared to 55.6% of those in the guideline-recommended treatment group (odds ratio of 0.87; P=0.06).  The rate of death was also similar between the two groups (11.9% vs. 12%; P=0.96).  However, a pre-specified ordinal analysis revealed significantly lower modified Rankin scores for patients who received early intensive treatment (odds ratio of 0.87; P=0.04), indicating better functional outcomes.

NEJM Deputy Editor Dr. Mary Beth Hamel states: “These findings suggest early, intensive blood pressure lowering may be safe, and possibly desirable, in patients with acute intracerebral hemorrhage.”

With that in mind, the best response to high blood pressure after intracerebral hemorrhage may be a prompt one.

How do you currently manage patients with acute intracerebral hemorrhage and elevated SBP?  At what threshold do you initiate treatment, and what lower level of SBP do you target (if any)?  Will the results of the INTERACT2 trial change your approach?

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