Is Intensive BP Lowering Beneficial After Cerebral Hemorrhage?

Intensive blood pressure (BP) treatment is not superior to standard treatment in patients with acute cerebral hemorrhage, according to a recent study.

Acute cerebral hemorrhage is common and may be linked with hematoma expansion and increased mortality and disability. Previous trials that had evaluated the lowering of systolic BP within 6 hours of symptom onset had produced limited results.
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Therefore, the researchers in the present study designed the Antihypertensive Treatment of Acute Cerebral Hemorrhage II (ATACH-2) trial to determine whether rapidly lowering systolic BP earlier after symptom onset can reduce the rate of subsequent death or disability.

The researchers randomly assigned 1000 participants with intracerebral hemorrhage (volume <60 cm³) and a Glasgow Coma Scale score of 5 or more to either an intensive treatment group (BP target = 110-139 mm Hg) or a standard treatment group (BP target = 140-179 mm Hg).

Participants received intravenous nicardipine within 4.5 hours after symptom onset to lower BP, and the researchers tracked primary outcomes as death or disability, as defined by a score of 4 to 6 on a modified Rankin scale (ranging from 0 [no symptoms] to 6 [death]).

Within 3 days of randomization, 1.6% of participants receiving intensive treatment and 1.2% of those receiving standard treatment had a serious adverse event. However, participants receiving intensive treatment had a significantly higher rate of renal adverse events within the first week than those receiving standard treatment (9% and 4%, respectively). The rate of primary outcomes was similar between groups after 3 months (38.7% of participants receiving intensive treatment vs 37.7% of those receiving standard treatment).

“The treatment of participants with intracerebral hemorrhage to achieve a target systolic blood pressure of 110-139 mm Hg did not result in a lower rate of death or disability than standard reduction to a target of 140-179 mm Hg,” the researchers concluded.

—Amanda Balbi

Reference:

Qureshi AI, Palesch YY, Barsan WG, et al; ATACH-2 Trial Investigators and the Neurological Emergency Treatment Trials Network. Intensive blood-pressure lowering in patients with acute cerebral hemorrhage [published online June 8, 2016]. N Engl J Med. doi:10.1056/NEJMoa1603460.