Written by Mary Marschner
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Initiating an ACE inhibitor/angiotensin receptor blocker (ACE-I/ARB) in nonlobar intracerebral hemorrhage (ICH) improves 90-day functional status. Prior ACE-I/ARB use results in noninferior outcomes compared to new initiation.
Is ICH an indication for ACE-I/ARB? Perhaps…
ICH is the second most common stroke type, primarily caused by hypertension, followed by amyloid angiopathy or vascular malformation. Blood pressure management is key in hospitalized patients, often involving dose adjustments or new medications. This study suggests a preference for ACE-I/ARB.
This retrospective cohort study examined whether antihypertensive choice after nonlobar ICH affects 90-day functional outcomes in 1,079 patients. Favorable outcomes (modified Rankin Scale 0–3) were more likely with ACE-I/ARB initiation (adjusted OR 1.49; 95%CI, 1.08–2.05; P = .01). No other antihypertensive classes showed significant effects.
The study was limited by its size. However, it found that patients already on ACE-I/ARB had noninferior outcomes compared to those newly initiated. While it doesn’t tease out secondary prevention efficacy, it highlights the potential impact of specific antihypertensive classes on functional recovery.
How does this change my practice?
Though too small to fully convince me that ACE-I/ARBs are superior in the setting of hypertensive hemorrhage, I love ACE-I/ARBs as blood pressure agents! They are so well tolerated, have so many indications, and are my favorite antihypertensive medication for outpatients. But in the inpatient setting, we like to see blood pressure come down more quickly, which may be why it isn’t a favorite. My other takeaway was that 30% of patients were noncompliant with the medications by 90 days! Yikes.
Source
Antihypertensive Medication Class and Functional Outcomes After Nonlobar Intracerebral Hemorrhage. JAMA Netw Open. 2025 Feb 3;8(2):e2457770. doi: 10.1001/jamanetworkopen.2024.57770. PMID: 39899295
