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Betting on Intensive BP Reduction to Improve Outcomes After ICH

Summary and Comment |
August 14, 2012

Betting on Intensive BP Reduction to Improve Outcomes After ICH

  1. Hooman Kamel, MD

An analysis of INTERACT1 raises the hope that intensive blood pressure reduction ultimately will be shown to improve clinical outcomes.

  1. Hooman Kamel, MD

Intracerebral hemorrhage (ICH) often acutely increases blood pressure (BP). This hypertensive response may promote ongoing bleeding, but we do not know whether BP reduction improves clinical outcomes. To address this uncertainty, researchers conducted the INTERACT1 trial, randomizing 404 patients with ICH to intensive BP reduction (systolic BP target, 140 mm Hg) or standard BP control (≤180 mm Hg systolic). This pilot trial showed that intensive BP reduction decreased hematoma growth an average 1.7 mL more than standard BP control, but the trial lacked power to detect a significant difference in clinical outcomes, prompting the larger, ongoing INTERACT2 trial.

To gauge the likelihood that INTERACT2 will demonstrate a clinical benefit, the same investigators have now analyzed the association between hematoma growth and outcomes in INTERACT1. In models controlling for numerous potential confounders such as age, stroke severity, and hematoma volume, each 1-mL increase in hematoma growth was associated with a 5% greater risk for death or dependency (modified Rankin Scale score of 3–5) at 90 days. Therefore, the approximately 2-mL reduction in hematoma growth achieved by intensive BP reduction in INTERACT1 would, theoretically, result in a 10% improvement in clinical outcomes.

Comment

This analysis reinforces prior reports of an association between hematoma growth and poor outcomes after ICH. Hematoma growth might simply reflect more-severe illness and greater comorbidity, in which case reducing hematoma growth by lowering BP would not improve outcomes. Still, this study highlights the potential clinical payoff of reducing hematoma growth and raises hope for the success of INTERACT2. In the meantime, clinicians should follow the 2010 American Heart Association guidelines, which essentially advise a systolic BP target of 140–160 mm Hg. In selected patients at high risk for hematoma growth (e.g., those on anticoagulants or with a spot sign on computed tomographic angiography), aiming for the lower end of that range for the first 24 hours is reasonable.

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