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Original Investigation
September 8, 2020

Outcomes of Intensive Systolic Blood Pressure Reduction in Patients With Intracerebral Hemorrhage and Excessively High Initial Systolic Blood Pressure: Post Hoc Analysis of a Randomized Clinical Trial

Author Affiliations
  • 1Zeenat Qureshi Stroke Institute, University of Missouri, Columbia
  • 2Department of Neurology, University of Missouri, Columbia
  • 3Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor
  • 4Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, Maryland
  • 5China Medical University, Taichung, Taiwan
  • 6Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
  • 7Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
  • 8Division of Neurosciences Critical Care, The Johns Hopkins University School of Medicine, Baltimore, Maryland
  • 9Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
  • 10Center for Advancing Clinical and Translational Sciences, National Cerebral and Cardiovascular Center, Suita, Japan
JAMA Neurol. Published online September 8, 2020. doi:10.1001/jamaneurol.2020.3075
Key Points

Questions  What are the outcomes of intensive systolic blood pressure reduction in patients with intracerebral hemorrhage and excessively high initial systolic blood pressure (≥220 mm Hg)?

Findings  This post hoc analysis of a randomized clinical trial showed higher rates of neurological deterioration and no evidence of reducing hematoma expansion at 24 hours or death or severe disability at 90 days in those who underwent intensive systolic blood pressure reduction.

Meaning  The significantly higher rate of neurological deterioration associated with intensive treatment in patients with initial systolic blood pressure of 220 mm Hg or more warrants caution against broad recommendations for intensive systolic blood pressure reduction in patients with intracerebral hemorrhage.

Abstract

Importance  The safety and efficacy of intensive systolic blood pressure reduction in patients with intracerebral hemorrhage who present with systolic blood pressure greater than 220 mm Hg appears to be unknown.

Objective  To evaluate the differential outcomes of intensive (goal, 110-139 mm Hg) vs standard (goal, 140-179 mm Hg) systolic blood pressure reduction in patients with intracerebral hemorrhage and initial systolic blood pressure of 220 mm Hg or more vs less than 220 mm Hg.

Design, Setting, and Participants  This post hoc analysis of the Antihypertensive Treatment of Acute Cerebral Hemorrhage-II trial was performed in November 2019 on data from the multicenter randomized clinical trial, which was conducted between May 2011 to September 2015. 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.

Interventions  Intravenous nicardipine infusion titrated to goals.

Main Outcomes and Measures  Neurological deterioration and hematoma expansion within 24 hours and death or severe disability at 90 days, plus kidney adverse events and serious adverse events until day 7 or hospital discharge.

Results  A total of 8532 patients were screened, and 999 individuals (mean [SD] age, 62.0 [13.1] years; 620 men [62.0%]) underwent randomization and had an initial SBP value. Among 228 participants with initial systolic blood pressures of 220 mm Hg or more, the rate of neurological deterioration within 24 hours was higher in those who underwent intensive (vs standard) systolic blood pressure reduction (15.5% vs 6.8%; relative risk, 2.28 [95% CI, 1.03-5.07]; P = .04). The rate of death and severe disability (39.0% vs 38.4%; relative risk, 1.02 [95% CI, 0.73-1.78]; P = .92) was not significantly different between the 2 groups. There was a significantly higher rate of kidney adverse events in participants randomized to intensive systolic blood pressure reduction (13.6% vs 4.2%; relative risk, 3.22 [95% CI, 1.21-8.56]; P = .01), but no difference was observed in the rate of kidney serious adverse events.

Conclusions and Relevance  The higher rate of neurological deterioration within 24 hours associated with intensive treatment in patients with intracerebral hemorrhage and initial systolic blood pressure of 220 mm Hg or more, without any benefit in reducing hematoma expansion at 24 hours or death or severe disability at 90 days, warrants caution against generalization of recommendations for intensive systolic blood pressure reduction.

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