1. Intensive lowering of blood pressure in patients with intracerebral hemorrhage did not produce a significant reduction in the primary end point of death or major disability at 90 days.
2. Intensive lowering of blood pressure did reduce the degree of disability at 90 days.
3. Intensive lowering of blood pressure is not associated with increased adverse events.
Evidence Rating Level: 1 (Excellent)
Study Rundown: Acute intracerebral hemorrhage is a form of stroke often accompanied by elevated blood pressures. These pressures must be controlled, but it is not clear what the target blood pressure should be. In 2008, the INTERACT trial showed that a target systolic pressure of 140 mm Hg (compared to a guideline-based target of 180 mm Hg) reduced the volume of blood that accumulated in the brain and did not increase adverse events. This was the basis for the INTERACT2 trial, summarized below.
In this trial, the authors were unable to show a significant reduction in the primary end point of death or major disability at 90 days. The final odds ratio was 0.87 (P=0.06). However, a secondary analysis looking more closely at the distribution of disability scores suggests that the intensive treatment strategy does reduce disability overall. In addition, the safety data show that the intensive treatment is well-tolerated.
Although these data suggest benefit and do not show harm from intensive blood pressure management, the matter may not be resolved until the results of additional trials are released.
In-Depth [randomized controlled trial]: Nearly 3000 patients with acute intracerebral hemorrhage at centers around the world were randomized to either an intensive treatment strategy targeting a systolic blood pressure of less than 140mmHg within 1 hour of randomization and maintained for 7 days, or a guideline-based standard treatment where blood pressure-lowering treatment was only administered if the blood pressure was higher than 180mmHg.
The primary outcome was death or major disability at 90 days, evaluated using the modified Rankin scale, which ranges from 0 (no symptoms) to 6 (death). Major disability was defined as a score from 3 to 5. The odds ratio for intensive treatment compared to standard treatment was 0.87 (95% CI, 0.75 to 1.01, P=0.06). However, an ordinal analysis showed that the distribution of Rankin scores in the intensive treatment group was shifted towards lower scores, implying less disability.
By Tomi Jun and Mitalee Patil
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