In this episode, I’ll discuss how aggressively extremely high blood pressure should be managed in patients with ICH.
AHA guidelines for the management of spontaneous intracerebral hemorrhage (ICH) split hypertension management recommendations into two groups based on the strength of available evidence. The first group is those with a blood pressure of 150 to 220 mmHg systolic, and there is class I level A evidence to suggest lowering blood pressure in these patients to a systolic of 140 mmHg is safe. In patients with a systolic above 220 mmHg, the level of evidence drops down to class IIb level C with a recommendation to consider aggressive reduction in blood pressure for these patients. It is believed that lowering blood pressure in these patients will reduce the risk of hematoma expansion and associated worsening of neurologic function.
In an effort to add to the level of evidence for the population of patients with ICH and SBP above 220 mmHg, a group of authors published in JAMA Neurology a post hoc analysis of the Antihypertensive Treatment of Acute Cerebral Hemorrhage-II trial.
Patients with intracerebral hemorrhage and initial systolic blood pressure of 180 mm Hg or more, randomized within 4.5 hours after symptom onset, were included.
The treatment administered was a nicardipine continuous infusion titrated to two different blood pressure goals. The intensive goal was 110-139 mm Hg and the standard goal was 140-179 mm Hg.
The efficacy measures were neurological deterioration and hematoma expansion within 24 hours and death or severe disability at 90 days. The safety outcomes were s kidney adverse events and serious adverse events until day 7 or hospital discharge.
Out of the original study’s 999 patients, 228 had an initial systolic blood pressure of 220 mm Hg or more. In this analysis, the rate of neurological deterioration within 24 hours was higher in those who underwent intensive systolic blood pressure reduction at 15.5% compared to just 6.8% in the standard group, with a relative risk of 2.28. The rate of hematoma expansion, death, and severe disability was not significantly different between groups, nor was the rate of kidney serious adverse events. When this was broadened to look at all kidney adverse events, the rate was higher in the intensive reduction group at 13.6% vs 4.2% with a relative risk of 3.22.
This study expands the available data comparing different blood pressure management goals in this patient population and argues against a blanket recommendation for intensive blood pressure lowering in ICH patients with a systolic over 220 mmHg and in favor of cautiously choosing the intensity of blood pressure reduction for these patients. However, the study was a post-hoc analysis, not a pre-specified one. This weakens the level of evidence as a post-hoc analysis should generally be considered hypothesis-generating for future studies but not practice-changing due to the risk of being a random finding.
Members of my Hospital Pharmacy Academy have access to practical training from a pharmacist’s point of view on acute blood pressure management in stroke, and the pharmacist’s role on a stroke alert team. This is in addition to many other resources to help in your practice. To get immediate access, go to pharmacyjoe.com/academy.
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