The Sweet Spot for BP in ICH

Written by Sam Parnell

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For patients with acute intracerebral hemorrhage (ICH), intensive lowering of systolic blood pressure (SBP) with goal <140 mmHg was associated with increased cerebral ischemia and neurologic deterioration compared to goal SBP <160 mmHg. Cerebral ischemia and worse neurologic outcomes were particularly associated with allowing SBP to drop below 120 mmHg.

Why does this matter?
ICH is a common cause of death and disability and accounts for 10-25% of all strokes.  Blood pressure management in acute ICH has been causing headaches for clinicians and researchers for decades. If too high, the risk of bleeding is increased. If too low, there is increased risk of cerebral ischemia. Optimal blood pressure goal in ICH has been elusive.  See ATACH-2 for more background.

Not too high…not too low…just right
This was a retrospective study of patients at a single tertiary care center with primary diagnosis of ICH, 1 year before and after an institutional protocol change in SBP from target <160 mmHg to <140 mmHg.  They compared the incidence of acute cerebral ischemia and neurologic outcome for 119 patients with ICH who had a goal SBP <160 mmHg compared to SBP <140 mmHg.  Included patients had an MRI during the hospitalization.  Over the first 24 hours of hospitalization, patients with SBP goal <140 mmHg had lower mean SBP (134 vs 143 mm Hg) and lower minimum SBP over 72 hours (106 vs 112 mm Hg). Acute cerebral ischemia was significantly more frequent in patients with SBP goal <140 mmHg compared to patients with SBP <160 mmHg (32% vs 16%) as was acute neurologic deterioration (19% vs 5%). A minimum SBP ≤120 mm Hg over 72 hours was associated with cerebral ischemia, while no patient with a minimum SBP ≥130 mm Hg had cerebral ischemia.  This study had a relatively small sample size, with many patients being excluded, so exercise caution.  For me, the results are compelling and will change my practice for patients with acute ICH.  Setting a lower limit on SBP in patients with ICH of around 140 and avoiding drops <120 mmHg may help avoid cerebral ischemia and neurologic deterioration.

Source
Cerebral ischemia and deterioration with lower blood pressure target in intracerebral hemorrhage.  Neurology. 2018 Aug 10. pii: 10.1212/WNL.0000000000006156. doi: 10.1212/WNL.0000000000006156. [Epub ahead of print]
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Reviewed by Thomas Davis and Clay Smith