Blood pressure management in intracerebral hemorrhage

Abstract

Elevated blood pressure (BP) independently predicts poor outcomes for patients with acute intracerebral hemorrhage (ICH). The INTERACT2 trial published in 2013 is found to produce better functional outcomes without harming patients with ICH who underwent early intensive BP lowering (systolic BP target <140 mmHg) within 6 hours of onset. These outcomes resulted in revisions of guidelines for the acute BP management of patients with ICH, in which, intensive BP lowering is recommended as safe and effective for improving functional outcomes. However, the ATACH-II trial found no difference in the frequency of death and disability at 90 days between patients treated with “very early” (<4.5 hours of onset) and “very rapid and intensive” BP lowering (systolic BP <140 mmHg with intravenous nicardipine for 24 hours) and with standard BP management. Therefore, a lower limit of target BP and an optimal method of reducing BP remain to be clarified. Evidence does support the notion that long-term BP lowering is the single most significant intervention for the secondary prevention of ICH. Several guidelines recommend a target BP of <130/80 mmHg after ICH, but this is supported by limited evidence. An ongoing randomized controlled trial (TRIDENT) is aiming to determine the effectiveness of more intensive BP lowering using a fixed low-dose combination of agents such as telmisartan, amlodipine, and indapamide (“Triple Pill” strategy) in addition to standard care, on the time to first occurrence of recurrent stroke among over 4,200 patients with ICH worldwide, including Japan.