Category: Critical Care
Keywords: INTERACT 2, ATACH II, Intracranial Hemorrhage, Hypertensive Emergency, Hemodynamics (PubMed Search)
Posted: 2/24/2014 by John Greenwood, MD
(Emailed: 2/25/2014)
(Updated: 2/25/2014)
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Intensive BP Control in Spontaneous Intracranial Hemorrhage
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.
An emerging concept is that rapid and aggressive BP control (target SBP of 140) may reduce hematoma formation, secondary edema, & improve outcomes.
Recently published, the INTERACT 2 trial (n=2,829) compared intensive BP control (target SBP < 140 within 1 hour) to standard therapy (target SBP < 180) found:
Study flaws: Patients treated with multiple drugs - combinations of urapadil, labetalol, nicardipine, nitrates, hydralazine, and diuretics. Management variability away from protocol seemed high. (Interesting editorial)
A Post-hoc analysis of the INTERACT 2 published just this month suggests that large fluctuations in SBP (>14 mmHg) during the first 24 hours may increase risk of death & major disability at 90 days.
Bottom Line: INTERACT 2 was a large RCT but not a great study (keep on the look out for ATACH II). 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.
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