A 76-year-old female presents to the emergency department obtunded with left hemiplegia. Symptoms began just prior to presentation. Her blood pressure (BP) is 195/104 mmHg. The CT scan reveals a hemorrhage in the right internal capsule, suggestive of acute hypertensive hemorrhagic stroke. Should the BP be treated aggressively, what is the target, and how quickly should we achieve that target?

Background

There have been a couple of large and influential trials published on BP management after an intracranial hemorrhage (ICH). Both INTERACT-2 and ATACH-2 showed no statistical difference in their primary outcome between intensively lowering the BP and a less-intensive strategy.^1,2

The 2022 AHA/ASA Guidelines give several recommendations on this topic.³ The class (strength) of their recommendation is 2a/2b based upon Level B and Level C quality of evidence. The language used in the guidelines is important. The specific language used in the AHA/ASA guidelines is as follows:

• “In patients with spontaneous ICH in whom acute BP lowering is considered, initiating treatment within 2 hours and reaching target within 1 hour can be beneficial to reduce the risk of HE [hematoma expansion] and improve functional outcome”
  • Class 2a recommendation, “Moderate”: is reasonable, can be beneficial; level of evidence C-LD (limited data)
• “In patients with spontaneous ICH of mild to moderate severity presenting with SBP [systolic BP] between 150 and 220 mmHg, acute lowering of SBP to a target of 140 mmHg with the goal of maintaining in the range of 130 to 150 mmHg is safe and may be reasonable for improving functionaloutcomes.”
  • Class 2b recommendation, “Weak”: may be reasonable, may be beneficial, effectiveness not well established; level of evidence B-R (randomized; moderate quality evidence from 1 or more randomized controlled trials or meta-analyses of moderate-quality randomized controlled trials)
• “In patients with spontaneous ICH presenting with large or severe ICH or those requiring surgical decompression, the safety and efficacy of intensive BP lowering are not well established.”
  • Class 2b recommendation, “Weak”: may be reasonable, may be beneficial, effectiveness not well established; level of evidence C-LD (limited data)

Clinical Question

Can the implementation of a goal-directed care bundle, incorporating protocols for early, intensive BP lowering in addition to management algorithms for hyperglycemia, pyrexia, and abnormal anticoagulation, implemented in a hospital setting, improve outcomes for patients with acute spontaneous intracerebral hemorrhage?

Reference

Ma LM, Hu X, Song L, et. al. The third intensive care bundle with blood pressure reduction in acute cerebral haemorrhage trial (INTERACT3): an international, stepped wedge cluster randomised controlled trial. Lancet. 2023;402(10395):27-40.