Prof. Craig Anderson

Early intensive lowering of blood pressure may have some benefit in patients with in acute intracerebral haemorrhage (ICH), an Australian-led systematic review has found

Professor Craig Anderson, Professor of Neurology and Epidemiology at the University of NSW presented findings at the European Stroke Organisation (ESO)-World Stroke Organisation (WSO) 2020 Virtual Conference showing a 25% reduction in haematoma volume growth in the first 24 hours in patients who had early lowering of BP after ICH.

But uncertainty persists over the timing and strategy of BP lowering, he told the virtual meeting.

Professor Anderson told the meeting that until now, scientific studies have not yet sufficiently explained what are the benefits from intensive BP lowering in patients with haemorrhagic stroke.

Therefore, a systematic review with meta-analysis was conducted of the Cochrane Central Register of Controlled Trials, EMBASE and MEDLINE databases to identify randomised controlled trials of BP management in adults with acute ICH.

The authors were able to use individual patient data from 16 randomised controlled trials on BP management within seven days of the onset of the acute disease process in adult patients with haemorrhagic insult.

Overall, these studies included 6,221 patients eligible for analysis (mean age of 64 years, 36% females, median time at enrolment 3.8 hours after onset of symptoms).

Intensive antihypertensive therapy lowered the BP median to 158.6 mmHg systolic within an hour after treatment began (placebo: 166 mmHg) and a median of 144.3 mmHg within 24 hours (placebo: median of 156.4 mmHg).

However, the difference between treatment arms was again smaller in the period between two to seven days (median systolic BP 143.7 mmHg in the intensive treatment arm and 151 mmHg with placebo).

The primary outcome (primary evaluation criterion) was functional status, defined by the modified Rankin Scale (mRS score; 0-6) at 90 days after acute ICH.

The authors also evaluated the proportional change in haematoma growth with therapy being provided.

The review found that early BP lowering in patients with ICH was not accompanied by a statistically significant improvement in function at day 90 after the acute insult (Odds Ratio: 0.97; p=0.503).

However, patients in the intensive BP treatment arm did show reduced haematoma volume growth in the first 24 hours (odds ratio: 0.75; p=0.007).

The subgroup of patients treated with a BP target did show a potential benefit when compared with patients treated based on a drug class.

“Further studies are needed to understand this somewhat contradictory finding of the main outcomes and to identify the best timing, BP lowering strategy, and drug classes to show a potential clinical benefit,” concluded Professor Anderson.