How low can you go?
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The document discusses blood pressure management in patients with acute intracerebral hemorrhage (ICH), highlighting the importance of appropriate targets for blood pressure reduction and the potential benefits of lowering systolic blood pressure to 140 mm Hg. Evidence suggests that aggressive management may be beneficial for patients presenting with high blood pressure levels, yet there are uncertainties regarding the effectiveness and safety of such interventions. Clinical guidelines recommend careful monitoring and tailored treatment strategies based on individual patient conditions and evidence from ongoing trials.
How low can you go?
- 1. Ersifa Fatimah | 2016 How Low Can You Go? Blood-Pressure Management in Patients with Acute Cerebral Hemorrhage
- 2. Elevated Blood Pressure in Stroke Ischaemic vs Haemorrhagic Mechanism Management The mechanisms implicated for elevated BP include pre-existing hypertension, premorbid acute or persistent elevations in BP, activation of neuro- endocrine systems, pain, stress of hospitalisation, lesion topography, stroke subtype, stroke severity, raised intracranial pressure
- 3. BP Control in Cerebrovascular Emergencies Emergency BP Target Rationale Acute ischemic stroke - Small vessel disease - Large vessel disease - Cardiac problem - Post thrombolysis Intracerebral hemorrhage Subarachnoid hemorrhage
- 4. Determinants of Blood Pressure BP blood pressure, CO cardiac output, SVR systemic vascular resistances, SV stroke volume, HR heart rate, CNS central nervous system Fred Rincon, Jack C. Rose, and Stephan A. Mayer. Blood Pressure Management After Central Nervous System In A.J. Layon et al. (eds.), Textbook of Neurointensive Care, Springer-Verlag London 2013
- 5. Cerebral Autoregulation Zacharia, B. & Connolly Jr., E., 2013. Principles of Cerebral Metabolism and Blood Flow. I n P.D. Le Roux, J.M. Levine & W.A. Kofke, eds. Monitoring in Neurocritical Care. Philadelphia: Elsevier. pp.2-7. CPP = MAP - ICP
- 6. Cerebral autoregulation in normal and chronically hypertensive patients William B. Owens, Blood Pressure Control in Acute Cerebrovascular Disease, J Clin Hypertens (Greenwich). 2011; 13: 205–211.
- 7. Should we reduce BP in acute ICH? No, increased BP is necessary Yes, increased BP is harmful Hematoma expansion is a reality Is there evidence of perihematoma ischemia??
- 8. BP-lowering trials for acute ICH Lisa S. Manning & Thompson G. Robinson. New Insights into Blood Pressure Control for Intracerebral aemorrhage. In Toyoda K, Anderson CS, Mayer SA (eds): New Insights in Intracerebral Hemorrhage. Front Neurol Neurosci. Basel, Karger, 2016, vol 37, pp 35–50
- 12. Supplement to: Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med 2013;368:2355-65. … …
- 14. 1. The suggested BP targets in patients with acute ICH are described below (LOE III, GOR B). Drugs that can be used for BP control in spontaneous ICH are shown in Table 2 (revised recommendation). 1) If the SBP is >200 mm Hg or MAP is >150 mm Hg, then consider aggressive BP reduction with a continuous intravenous infusion of drugs, with frequent BP monitoring every 5 minutes. 2) If the SBP is >180 mm Hg or MAP is >130 mm Hg and there is any possibility of an ICP elevation, then consider ICP monitoring and reducing BP using an intermittent or continuous intravenous infusion while maintaining a CPP (MAP-ICP) of 50–70 mm Hg. 3) If the SBP is >180 mm Hg or MAP is >130 mm Hg and there is no evidence of an ICP elevation, then consider a modest reduction of BP using an intermittent or continuous intravenous infusion (MAP of 110 mm Hg for a BP of 160/90 mm Hg) and clinically re- examine the patient every 15 minutes. 2. In patients with acute ICH, when the SBP is measured between 150 and 220 mm Hg, the SBP may be safely lowered to 140 mm Hg within 1 hour (LOE Ib, GOR A) (new Recommendation). Intracerebral Hemorrhage Stroke - The Management of Blood Pressure Update Guideline Recommendations 1. For ICH patients presenting with SBP between 150 and 220 mm Hg and without contraindication to acute BP treatment, acute lowering of SBP to 140 mm Hg is safe (Class I; Level of Evidence A) and can be effective for improving functional outcome (Class IIa; Level of Evidence B). (Revised from the previous guideline) 2. For ICH patients presenting with SBP >220 mm Hg, it may be reasonable to consider aggressive reduction of BP with a continuous intravenous infusion and frequent BP monitoring (Class IIb; Level of Evidence C). (New recommendation) Kim at al., Korea, 2014 1. Until ongoing clinical trials of BP intervention for ICH are completed, physicians must manage BP on the basis of the present incomplete efficacy evidence. Current suggested recommendations for target BP in various situations are listed in Table 6 and may be considered (Class IIb; LOE C). (Unchanged from the previous guideline) 2. In patients presenting with a systolic BP of 150 to 220 mmHg, acute lowering of systolic BP to 140 mmHg is probably safe (Class IIa; LOE B). (New recommendation) Hemphill et al., AHA/ASA, 2015 Morgenstern et al., AHA/ASA, 2010 In acute ICH within 6 h of onset, intensive blood pressure reduction (systolic target <140 mmHg in <1h) is safe and may be superior to a systolic target <180 mmHg. No specific agent can be recommended. Steiner et al., ESO, 2014 Hemphill et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage : A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke, published online May 28, 2015. Kim et al. Clinical Practice Guidelines for the Medical and Surgical Management of Primary Intracerebral Hemorrhage in Korea. J Korean Neurosurg Soc 56 (3) : 175-187, 2014 Morgenstern et al. Association for Healthcare Professionals From the American Heart Association/American Stroke Guidelines for the Management of Spontaneous Intracerebral Hemorrhage : A Guideline. Stroke. 2010;41:2108-2129; originally published online July 22, 2010. Steiner et al. European Stroke Organisation (ESO) guidelines for the management of spontaneous intracerebral hemorrhage. Int J Stroke. 2014 Oct;9(7):840-55.
- 15. Guideline Discussion • No significant ischemic penumbra in ICH. The perihematomal rim of low attenuation seen on CT being related to extravasated plasma. • Small ischemic lesions identified on DWI are common after ICH impact on outcome and relationship with BP lowering vary across studies • No clear relationship between outcome and the time from onset of ICH to commencing treatment. Only 1/3 of patients achieved the target SBP level within 1 hour (half achieved the target by 6 hours), and most (75%) presented with mild to moderate size (<20 mL) hematomas. • The main mechanism for the improved outcomes with rapid intensive BP reduction is still unclear because there were no significant absolute or relative changes in hematoma growth between the two treatment groups. The hematoma volume difference between the groups was very small (adjusted mean volume, 1.4 mL). • There are fewer data available pertaining to the safety and effectiveness of such treatment in patients with very high BP (sustained SBP >220 mm Hg) on presentation, large and more severe ICH, and those requiring surgical decompression. • Because the speed and degree of BP reduction will vary according to the agent and method of delivery (bolus versus infusion) and clinical features, the choice of agent should take into account the practicability, pharmacological profile, potential side effects, and cost
- 17. The inclusion and exclusion criteria of the ATACH II trial A. I. Qureshi , Y. Y. Palesch. Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) II: Design, Methods, and Rationale. Neurocrit Care (2011) 15: 559–576
- 18. ATACH 2 INTERACT 2 Systolic blood pressure levels at and after randomization. The lines incorporate blood pressure values with 95% confidence intervals represented by the vertical bars. The differences in mean systolic blood pressure are given for the intensive group as compared with the guideline- recommended group are given for 1 and 6 hours post- randomization. All between group blood pressures are significant (P<0.0001) from 15 minutes. Mean Hourly Minimum Systolic Blood Pressure during the First 24 Hours after Randomization, According to Treatment Group. The dashed vertical line indicates 2 hours, and I bars 95% confidence intervals. ATACH-II vs INTERACT2: Conflicting Results? Key Difference: INTERACT2 achieved moderate blood pressure reduction, while patients in the intensive arm of ATACH-II had greater and faster blood pressure reduction The blunting of fluctuations in the systolic blood-pressure level in patients with intracerebral hemorrhage and an acute hypertensive response may exert a therapeutic benefit that is independent of the magnitude of lowering the systolic blood-pressure level.
- 19. Intensive lowering BP in ICH stroke: The questions remain • Feasible? • Safe? • Effective? • Knowledge gaps?
- 20. END. discussion
Editor's Notes
- #6: The exact pathological mechanisms underlying the association between elevated BP and outcome following ICH remain unclear. An underlying hypothesis relates to the effects of stroke on cerebral autoregulation. Cerebral autoregulation is impaired in acute stroke [13, 14] , and thus, cerebral perfusion becomes increasingly pressure de- pendent. Elevated BP or steep increases in BP may promote ongoing bleeding and haematoma expansion and may enhance the formation of cerebral oedema through oncotic or hydrostatic pressure gradients in the perihaematomal region [15, 16] . Fur- thermore, mass effects related to ICH and cerebral oedema may lead to elevations in intracranial pressure, which may compromise cerebral perfusion further in the pres- ence of elevated MAP. Data from clinical studies that support the above proposed hypotheses are limited.
- #15: CI 5 confidenceinterval;ICHADAPT 5 IntracerebralHemorrhageAcutelyDecreasingArterialPressureTrial;INTERACT 5 IntensiveBloodPressure ReductioninAcuteCerebralHemorrhageTrial;tx 5 treatment.
- #21: “ICH patients need to be admitted to a stroke care unit where they can be treated by stroke experts but if they are given IV antihypertensives they usually go to the intensive care unit or coronary care unit where they can deal with the risk of hypotension better. This is taking them away from the stroke specialists.” ATACH-II trial showed a higher occurrence of serious adverse events within 3 months & higher proportion of renal adverse events within 7 days after randomization in the intensive-treatment group ? ATACH-II provide data to indicate a change to current guidelines ? ATACH-II Published: Intensive BP Reduction Not Needed in ICH | Sue Hughes | Medscape | June 09, 2016 ATACH-II: No Benefit of Intensive BP Lowering in ICH | Sue Hughes | Medscape | May 18, 2016 56.2% of patients were Asian. last-minute delay to the ATACH-II publication