Title: Intensive BP Control in Spontaneous Intracranial Hemorrhage<br/>Author: John Greenwood<br/><a href='http://umem.org/profiles/faculty/412/'>[Click to email author]</a><hr/><p>
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<u><strong>Intensive BP Control in Spontaneous Intracranial Hemorrhage</strong></u></p>
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Managing the patient with hypertensive emergency in the setting of spontaneous intracerebral hemorrhage (ICH) is often a challenge. Current guidelines from the American Stroke Association are to target an SBP of between 160 - 180 mm Hg with continuous or intermittent IV antihypertensives. Continuous infusions are recommended for patients with an initial SBP > 200 mm Hg.<br />
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An <em>emerging concept</em> is that <strong>rapid and aggressive BP control (target SBP of 140) may reduce hematoma formation, secondary edema, & improve outcomes.</strong><br />
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Recently published, the <a href="http://www.nejm.org/doi/pdf/10.1056/NEJMoa1214609" target="_blank"><strong>INTERACT 2 trial </strong></a>(n=2,829) compared intensive BP control (target SBP < 140 within 1 hour) to standard therapy (target SBP < 180) found:</p>
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No difference in mortality (11.9% vs 12%, respectively)</li>
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Improved functional status (secondary outcome) with intensive BP control</li>
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Intensive lowering of BP in patients with acute ICH appears safe </li>
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<strong>Study flaws: </strong>Patients treated with multiple drugs - combinations of urapadil, labetalol, nicardipine, nitrates, hydralazine, and diuretics. Management variability away from protocol seemed high. (<a href="http://stroke.ahajournals.org/content/44/10/2951.long" target="_blank">Interesting editorial</a>)<br />
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A<em> <a href="http://www.ncbi.nlm.nih.gov/pubmed/24530176" target="_blank">Post-hoc analysis of the INTERACT 2</a></em> published just this month suggests that <strong>large fluctuations in SBP (>14 mmHg) during the first 24 hours may increase risk of death & major disability at 90 days.</strong></p>
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<strong>Bottom Line: INTERACT 2 was a large RCT but not a great study (keep on the look out for <a href="http://link.springer.com/article/10.1007%2Fs12028-011-9538-3" target="_blank">ATACH II</a>). However, in patients with spontaneous ICH, consider early initiation of an antihypertensive drip (preferably nicardipine) in the ED to reduce blood pressure fluctuations early with a target SBP of 140 mmHg.</strong></p>
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<strong>Follow me on Twitter: @JohnGreenwoodMD</strong></p>
<fieldset><legend>References</legend>
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<a href="http://www.ncbi.nlm.nih.gov/pubmed/20651276" target="_blank">Morgenstern LB, Hemphill JC, Anderson C, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2010;41(9):2108-29.</a></li>
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<a href="http://www.ncbi.nlm.nih.gov/pubmed/23713578" target="_blank">Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013;368(25):2355-65.</a></li>
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<a href="http://www.ncbi.nlm.nih.gov/pubmed/23988644" target="_blank">Hill MD, Muir KW. INTERACT-2: should blood pressure be aggressively lowered acutely after intracerebral hemorrhage?. Stroke. 2013;44(10):2951-2.</a></li>
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<a href="http://www.ncbi.nlm.nih.gov/pubmed/24530176" target="_blank">Manning L, Hirakawa Y, Arima H, et al. Blood pressure variability and outcome after acute intracerebral haemorrhage: a post-hoc analysis of INTERACT2, a randomised controlled trial. Lancet Neurol. 2014.</a></li>
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<a href="http://www.ncbi.nlm.nih.gov/pubmed/21626077" target="_blank">Qureshi AI, Palesch YY. Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) II: design, methods, and rationale. Neurocrit Care. 2011;15(3):559-76.</a></li>
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