Science Times: A Randomized Clinical Trial of Aggressive Blood Pressure Control in Patients With Acute Cerebral Hemorrhage

Spontaneous supratentorial intracerebral hemorrhage (ICH) affects 4 million patients worldwide each year.1,2 Although this is a heterogeneous disorder with a wide range of outcomes, overall mortality at 1 month is ≈40%, and only 25% of patients have a favorable outcome.1,2 Acute hypertension is patients with ICH is common and may be linked to hematoma growth, cerebral edema, and poor outcome.3,4 Precise blood pressure guidelines and timing of implementation remain unclear.

In the second Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2), patients with spontaneous ICH who had a systolic blood pressure of 150 to 220 mm Hg within 6 hours after symptom onset were randomly assigned to intensive treatment to lower their blood pressure (with a target systolic level of <140 mm Hg within 1 hour) or guideline-recommended treatment (with a target systolic level of <180 mm Hg) with the use of agents of the physician’s choosing.5 Among the 2794 participants for whom the primary outcome could be determined, 719 of 1382 participants (52.0%) receiving intensive treatment, compared with 785 of 1412 (55.6%) receiving guideline-recommended treatment, had a primary outcome event (death or major disability; odds ratio with intensive treatment, 0.87; 95% confidence interval [CI], 0.75-1.01; P = .06). The ordinal analysis showed significantly lower modified Rankin Scale scores with intensive treatment (odds ratio for greater disability, 0.87; 95% CI, 0.77-1.00; P = .04). Mortality was 11.9% in the group receiving intensive treatment and 12.0% in the group receiving guideline-recommended treatment. Nonfatal serious adverse events occurred in 23.3% and 23.6% of the patients in the 2 groups, respectively.

Critics of the trial noted that a greater effect might not have been realized because hematoma expansion and the rate of subsequent death or disability might be decreased with earlier and more aggressive reduction in blood pressure in high-risk patients with blood pressure levels >180 mm Hg (10-11). Recently, the results of the Antihypertensive Treatment of Acute Cerebral Hemorrhage II (ATACH-2) trial were published in the New England Journal of Medicine.6 The goal was to assess whether rapid lowering of systolic blood pressure level in patients in an earlier time window after symptom onset than that evaluated in previous trials leads to better outcomes.4,5

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