Blood Pressure Reduction After Acute Intracerebral Hemorrhage: How Early and How Low?

Intensive lowering of blood pressure did not outperform the standard approach in this limited study of patients with acute intracerebral hemorrhage.
Optimal blood pressure management is challenging in patients with acute intracerebral hemorrhage (ICH). Reducing BP too low can lead to cerebral ischemia from lack of perfusion, while maintaining BP too high can increase the size of the hemorrhage. In a multicenter trial (Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial; INTERACT), researchers in Asia and Australia randomized 404 adults with acute ICH diagnosed by computed tomography (CT) scan within 6 hours of onset and elevated systolic BP (150–220 mm Hg) to intensive BP reduction (target systolic BP, 140 mm Hg) or standard therapy (target systolic BP, 180 mm Hg). Use of antiplatelet and warfarin therapy was similar in the two groups.
After adjustment for initial hematoma volume and time from ICH onset to CT scan, mean proportional increase in hematoma volume at 24 hours did not differ significantly between groups. Risks for death or dependency at 90 days also were similar in the two groups. Use of recombinant activated factor VII did not affect results. The authors plan to continue with a larger trial (INTERACT2) to assess clinical outcomes after intensive BP reduction in patients with ICH.
Comment: Whether intensive lowering of BP is superior to "routine" lowering in patients with acute ICH remains to be seen. However, maintaining very high systolic and mean arterial pressures is unlikely to do any good. Modest lowering of BP to a systolic target of approximately 150 mm Hg (similar to the target in the intensive-reduction arm in this study) makes sense, and collective discussions among neurosurgeons, neurologists, and emergency medicine physicians can help establish a uniform approach within each institution.
— Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine April 18, 2008

Citation(s):

Anderson CS et al. Intensive blood pressure reduction in acute cerebral haemorrhage trial (INTERACT): A randomised pilot trial. Lancet Neurol 2008 May; 7:391.