Intracerebral hemorrhage: analysis supports tailored approach to SBP reduction

  • Qureshi AI & al.
  • JAMA Neurol
  • 08/09/2020

  • Susan London
  • Clinical Essentials
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Takeaway

  • Among patients with intracerebral hemorrhage having excessively high initial systolic BP (SBP; ≥220 mm Hg), intensive vs standard lowering led to greater neurologic deterioration, without benefit on other outcomes.

Why this matters

  • Guidelines note uncertainty surrounding intensive antihypertensive therapy in this population.
  • Editorial urges refining the "balance between generalizability, which makes a treatment applicable to the largest number of patients, and efficacy, which is optimized by selecting subgroups with characteristics that make them most likely to benefit."

Key results

  • 228 patients had initial SBP ≥220 mm Hg.
  • In this subset, intensive vs standard groups:
    • Similar death or severe disability at 90 days:
      • Rate: 39.0% vs 38.4%.
      • Relative risk: 1.02 (P=.92).
    • More neurologic deterioration within 24 hours:
      • Rate: 15.5% vs 6.8%.
      • Relative risk: 2.28 (P=.04).
    • More any-severity kidney adverse events:
      • Rate: 13.6% vs 4.2%.
      • Relative risk: 3.22 (P=.01).
    • Similar kidney serious adverse events:
      • Rate: 1.8% vs 0.8%.
      • Relative risk: 2.15 (95% CI, 0.20-23.33).

Study design

  • Post hoc analysis of multicenter, randomized controlled trial in intracerebral hemorrhage, initial SBP ≥180 mm Hg (Antihypertensive Treatment of Acute Cerebral Hemorrhage II trial).
  • SBP reduction initiated within 4.5 hours of symptom onset, continued for 24 hours: intensive (goal, 110-139 mm Hg) vs standard (goal, 140-179 mm Hg).
  • Main outcome: death or severe disability.
  • Funding: National Institute of Neurological Disorders and Stroke; others.

Limitations

  • Post hoc design.
  • Small subset with excessively high initial SBP.
  • Patients with severe neurologic injury, high intracranial pressure, brainstem compression were excluded.