Cerebral Microbleeds and the Effect of Intensive Blood Pressure Reduction on Hematoma Expansion and Functional Outcomes

Background: While acute hypertensive response (AHR) predicts worse outcome in intracerebral hemorrhage (ICH), the INTERACT-2 trial recently failed to definitively demonstrate a major benefit of intensive blood pressure reduction on these patients. A possible explanation is that the detrimental effect of AHR on outcome may differ among ICH patients with and without previous chronic hypertension. Objective: to explore whether the prognosis of patients with AHR during the acute phase of ICH differs according to the presence or absence of left ventricle hypertrophy (LVH), which is a marker of chronic hypertensive organ damage. Method: we performed a retrospective analysis of a prospective cohort of patients with primary ICH presenting to an academic hospital between January/2000 and December/2012 with age > 18 years, who had a transthoracic echocardiogram available. LVH was defined according to Penn convention. AHR was defined as systolic blood pressure > 180 mmHg on admission. Mantel-Haenszel test was initially used to assess if LVH status influenced the effect of AHR on mortality. For subsequent analyses, ICH patients were divided in 3 groups: without AHR (reference); AHR without LVH; AHR with LVH. A multivariate logistic regression model was then used to identify independent predictors of mortality at 30-days. Results: 430 patients met inclusion criteria. AHR was present in 196 (46.6%), LVH was present in 233 (54.2%); 30-day mortality was 15.6%. On Mantel-Haenszel test, we found a trend (p=0.09) suggesting that absence of LVH increased AHR effect on mortality (OR:1.64; 95% CI: 0.95-2.8; p=0.07). On multivariate analysis, patients with AHR without LVH had significantly higher mortality (OR: 2.65; 95%CI: 1.15 to 6.1; p=0.022) when compared to patients without AHR, after adjusting for baseline characteristics. There was only a trend towards increased mortality in the group of patients with AHR and LVH (OR:2.22; 95% CI: 0.99-5.0; p=0.053). Conclusions: Patients without chronic hypertension appear to be more susceptible to the detrimental effects of AHR during the acute phase of ICH. Stratification of patients with ICH may help to identify those that will have greater benefit with intensive blood pressure reduction in the acute phase of ICH.

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Randomized trial to assess safety and clinical efficacy of intensive blood pressure reduction in acute spontaneous intracerebral haemorrhage

Medical Journal Armed Forces India ◽

10.1016/j.mjafi.2017.03.010 ◽

2018 ◽

Vol 74 (2) ◽

pp. 120-125

Author(s):

Salil Gupta ◽

A.K. Abbot ◽

R. Srinath ◽

A.K. Tewari ◽

Aditya Gupta ◽

...

Keyword(s):

Blood Pressure ◽

Randomized Trial ◽

Clinical Efficacy ◽

Intracerebral Haemorrhage ◽

Blood Pressure Reduction ◽

Pressure Reduction ◽

Spontaneous Intracerebral Haemorrhage ◽

Intensive Blood Pressure

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Abstract 40: Risk of Recurrent Stroke by Fazekas Category and Relationship With Intensive Blood Pressure Reduction: A Secondary Analysis of the SPS-3 Trial

Stroke ◽

10.1161/str.50.suppl_1.40 ◽

2019 ◽

Vol 50 (Suppl_1) ◽

Author(s):

Adam de Havenon ◽

Jennifer Majersik ◽

Ka-Ho Wong ◽

David Tirschwell ◽

Natalia Rost

Keyword(s):

Blood Pressure ◽

Recurrent Stroke ◽

Blood Pressure Reduction ◽

Secondary Analysis ◽

Pressure Reduction ◽

Intensive Blood Pressure

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Regional differences in the response to acute blood pressure lowering after cerebral hemorrhage

Neurology ◽

10.1212/wnl.0000000000011229 ◽

2020 ◽

pp. 10.1212/WNL.0000000000011229

Author(s):

Kazunori Toyoda ◽

Yuko Y Palesch ◽

Masatoshi Koga ◽

Lydia Foster ◽

Haruko Yamamoto ◽

...

Keyword(s):

Blood Pressure ◽

Adverse Events ◽

Intracerebral Hemorrhage ◽

East Asia ◽

Functional Outcomes ◽

Intensive Treatment ◽

Hematoma Expansion ◽

Blood Pressure Lowering ◽

Pressure Lowering ◽

Intensive Blood Pressure

Objective:To compare the impact of intensive blood pressure (BP) lowering right after intracerebral hemorrhage (ICH) on clinical and hematoma outcomes among patients from different geographic locations, we performed a prespecified sub-analysis of the randomized, multi-national, two-group, open-label trial to determine the efficacy of rapidly lowering BP in hyperacute ICH (ATACH-2), involving 537 patients from East Asia and 463 recruited outside of Asia.Methods:Eligible patients were randomly assigned to a systolic BP (SBP) target of 110-139 mmHg (intensive treatment) or 140-179 mmHg (standard treatment). Pre-defined outcomes were: poor functional outcome (modified Rankin Scale score of 4-6 at 90 days), death within 90 days, hematoma expansion at 24 hours; and cardio-renal adverse events within 7 days.Results:Poor functional outcomes (32.0% versus 45.9%), death (1.9% versus 13.3%), and cardio-renal adverse events (3.9% versus 11.2%) occurred significantly less in patients from Asia than those outside of Asia. The treatment-by-cohort interaction was not significant for any outcomes. Only patients from Asia showed a lower incidence of hematoma expansion with intensive treatment (adjusted RR 0.56, 95% CI 0.38-0.83). Both Asian (3.53, 1.28-9.64) and non-Asian cohorts (1.71, 1.00-2.93) showed a higher incidence of cardio-renal adverse events with intensive treatment.Conclusions:Poor functional outcomes and death 90 days after ICH were less common in patients from East Asia than those outside of Asia. Hematoma expansion, a potential predictor for poor clinical outcome, was attenuated by intensive BP lowering only in the Asian cohort.Clinicaltrials.gov identifierNCT01176565.Classification of evidence:This study provides Class II evidence that, for patients from East Asia with intracerebral hemorrhage, intensive blood pressure lowering significantly reduces the risk of hematoma expansion.

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