|Under Pressure, the 1981 classic by Queen in collaboration with David Bowie|
- Explore the data for safety and efficacy of urgent BP lowering in hemorrhagic stroke.
- Is there any benefit from management of elevated BP in acute ischemic stroke that is not a candidate for tPA?
- What is the data for BP target in aSAH awaiting definitive management?
- Elevated BP is very common in acute hemorrhagic stroke
- There is an association with elevated BP and:
- Increase in hematoma size
|Qureshi A, Palesch Y, Barsan W, Hanley D, Hsu C, Martin R et al. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. New England Journal of Medicine. 2016;375(11):1033-1043.|
- Large randomized, multi-centere, open label, international study
- Like INTERACT, the outcome assessors were blinded
- N was 1000 – stopped early for futility of primary outcome
- Compared intensive 110-139 systolic vs 140-179 systolic
- Initially included from 3 hours of onset, increased to 4.5 hours
- Primary outcome was death or major disability
- sBP >240 x 2 measurements
- known neoplasm/AVM/aneurysm
- candidate for immediate neurosurgical intervention
- not a ICU candidate.
They screened 8500 patients and recruited 1000 patients. The initial goal was 1280. The mean SBP on presentation was just over 200 systolic. The baseline characteristics were very similar to both groups.
Comparing this population to the INTERACT study they were less sick with 56% having a GCS of 15.
The INTERACT study also included patients with lower BP whereas to be included in this study your arrival BP had to be >180.
The other very important point here is the mean hematoma volume. Dr Dowlatshahi has looked at a few studies in terms of the natural progression of these small volume hematomas and it seems that under 10 cc these hematomas don’t tend to expand, so they may not be the ones to benefit from rapidly decreasing the BP.
- Standard therapy should target systolic BP <180
- Consider <160 in large hematomas/worsening clinically/sick enough for ICU
- I would say the current guidelines have this one incorrect. There is insufficient evidence to rapidly reduce to < 140 systolic
- is commonly elevated
- Usually transiently
- Likely secondary to both the stroke and non-stroke factors
- 2011 Lancet Study
- 9 Northern European Countries
- Double blind RCT
- Looked at candesartan vs placebo in acute ischemic and hemorrhagic stroke
- Single Blind RCT
- Used multiple antihypertensives
- 2014 study in JAMA
- Primary outcome was death or major disability at discharge or 14 days
- Target reduce BP by 10-25% in first 24 hours