Intensive Blood Pressure Control Might Not Reduce Death or Major Disability, but May Improve Quality of Life After Acute Intracerebral Hemorrhage

EBM Focus - Volume 8, Issue 27

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Reference: N Engl J Med 2013 Jun 20;368(25):2355, (level 2 [mid-level] evidence)

Blood pressure is commonly elevated following acute intracerebral hemorrhage. Current guidelines from the American Heart Association suggest a “modest reduction” if systolic pressure is > 180 mm Hg (Stroke 2010 Sep;41(9):2108), but the optimal blood pressure target is unclear. The INTERACT2 randomized trial compared intensive blood pressure control to guideline-recommended treatment in 2,839 patients with acute intracerebral hemorrhage.

Patients within 6 hours of onset of intracerebral hemorrhage who had systolic blood pressure 150-220 mm Hg were randomized to 1 of 2 treatment strategies and were followed for 90 days. The intensive blood pressure control strategy targeted a systolic blood pressure of < 140 mm Hg with the goal of reaching the target within 1 hour and then maintaining it for 7 days. Under the guideline-recommended strategy, the target systolic blood pressure was < 180 mm Hg. Agents used for blood pressure control were at the treating physicians’ discretion. All patients received oral antihypertensive drugs or topical nitrates within 7 days. History of hypertension was common (72%), and 45% were already taking antihypertensive drugs. The mean systolic blood pressure attained at 1 hour was 150 mm Hg with intensive control and 164 mm Hg with guideline-recommended treatment (33.4% in intensive control group achieved target systolic pressure at 1 hour).

The primary outcome was a composite of death or major disability (defined as modified Rankin score 3-5). Intensive control was associated with a nonsignificant decrease in the primary outcome (52% vs. 55.6%, p = 0.06), but there was no significant difference in mortality (11.9% vs. 12%). There were also no significant differences in the rates of nonfatal serious adverse events (23.3% vs. 23.6%) or neurologic deterioration in first 24 hours (14.5% vs. 15.1%). However, intensive blood pressure control was associated with improved quality of life outcomes. At 90 days, patients in the intensive control group had significantly lower rates of problems with self-care (46.8% vs. 51.6%, p = 0.02, NNT 21), usual activities (60.8% vs. 66.1%, p = 0.006, NNT 19), and pain and discomfort (39.8% vs. 45%, p = 0.01, NNT 20).

For more information, see the Intracerebral hemorrhage topic in DynaMed.

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