Early Blood Pressure-Lowering Effective Following Intracerebral Hemorrhage

Intensive blood pressure (BP) lowering within hours of intracerebral hemorrhage (ICH) onset is safe and improves functional recovery, according to findings published in The Lancet Neurology.

Researchers conducted an individual patient-data pooled analysis of the 4 Intensive Blood Pressure Reduction in Cerebral Hemorrhage (INTERACT) trials to assess the safety and effectiveness of early intensive BP lowering in patients with ICH. Of these, 3 were international, multicenter, open-label, blinded-endpoint, randomized controlled trials of adults with acute ICH who presented within 6 hours of symptom onset and had a systolic BP greater than 150 mm Hg. The fourth was an open-label, blinded-endpoint randomized controlled trial involving adult patients with suspected acute stroke and motor deficit who presented within 2 hours of symptom onset and had a systolic BP greater than 150 mm Hg.

The study’s primary outcome was physical function at follow-up, according to the modified Rankin scale. Safety outcomes included neurologic deterioration, treatment-related symptomatic hypotension, and fatal or non-fatal cardiac or renal serious adverse events. Proportional odds regression and logistic regression models were employed for statistical analysis.

A total of 11,312 participants were included, of whom the mean (SD) age was 63 (12.7) years, 64.1% were men, 47.3% received early intensive BP-lowering treatment, and 52.7% received guideline-recommended treatment. Median time from ICH symptom onset to randomization was similar between the intensive and guideline group, at 2.9 (IQR, 1.8-4.0) and 3.0 (IQR, 1.8-4.1) hours, respectively. However, mean systolic BP was significantly lower in the intensive group at all timepoints, with a mean difference of 9.13 mm Hg at 1 hour (95% CI, 8.28-10.00; P <.0001) and 5.60 mm Hg over 24 hours (95% CI, 5.30-5.90; P <.0001).

Patients receiving intensive BP-lowering treatment had a significantly decreased likelihood of poor physical functional recovery (odds ratio [OR], 0.85; 95% CI, 0.78-0.91). No significant interaction was observed between BP-lowering treatment and time from symptom onset to randomization.

Intensive BP-lowering treatment was associated with significantly lower risk for neurologic deterioration within 7 days (OR, 0.76; 95% CI, 0.66-0.88; P =.0002), death (OR, 0.83; 95% CI, 0.75-0.94; P =.002), or serious adverse event (OR, 0.84; 95% CI, 0.76-0.92; P =.0003). Among patients with baseline hematoma volume data (n=5134), functional recovery was significantly improved with intensive BP-lowering treatment (OR, 0.87; 95% CI, 0.79-0.99; P =.0052).

In a substudy of 2921 patients with available sequential brain computerized tomography data (mean [SD] age, 64.0 [12.6]; men, 65.5%), those who received intensive BP-lowering treatment (n=1454) had significantly higher likelihood of functional recovery compared with those receiving guideline treatment (n=1467; OR, 0.87; 95% CI, 0.76-0.99; P =.04). The researchers observed no effect for intensive BP-lowering treatment on relative (OR, 0.85; 95% CI, 0.70-1.03; P =.09) or absolute (OR, 0.84; 95% CI, 0.68-1.04; P =.12) hematoma growth at 24 hours, though the effects of treatment on relative hematoma growth decreased with increasing time from onset to randomization.

Study limitations include the use of different drug therapies and the open assignment of interventions.

“Initiating treatment soon after the onset of intracerebral haemorrhage reduces haematoma growth and enhances outcomes, with the greatest benefit apparent within 3 [hours],” the authors wrote.

Disclosures: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.