BLOOD PRESSURE LOWERING IN

CEREBRAL HEMORRHAGE

PATIENTS

Lauren ByrnesPharmacy InternAlbany College of Pharmacy and Health Sciences

PRESENTATION OVERVIEW Brief review of intracranial hemorrhaging (ICH) Review of current AHA/ASA guidelines Qureshi A, Palesch Y, Barsan W, Hanley D, Hsu C, Martin R et al. article

Conclusions Questions

INTRACRANIAL HEMORRHAGE Definition Type of bleeding that occurs within the skull

Incidence Crude incidence is approximately 15.9 per 100000

Mortality rates 34.6% at 7 days 50.3% at 30 days 59% at 1 year Diabetes mellitus and posterior fossa hemorrhage had higher mortality rates

GUIDELINES FOR THE MANAGEMENT OF SPONTANEOUS

INTRACEREBRAL HEMORRHAGEHemphill J, Greenberg S, Anderson C, Becker K, Bendok B, Cushman M et al.

CURRENT BLOOD PRESSURE LOWERING GUIDELINES Elevated BP in ICH Very common symptom of acute ICH Generally due to stress, pain, increase intracranial pressure (ICP) and premorbid acute or persistent high BP

High systolic blood pressure (SBP) generally associated with greater neurological detriment, death, hematoma expansion and dependency post ICH

Current Guidelines ICH patients with SBP between 150 and 220 mmHg

Reduce to SBP to 140 mmHg ICH patients with SBP >220 mmHg

Aggressive reduction with IV infusion and frequent monitoring

CURRENT STANDARD OF CARE Nicardipine Used to lower patients to <160 mmHg Current standard of care Based on ATACH (Antihypertensive Treatment of Acute Cerebral Hemorrhage) trial

BP Lowering Presenting with SBP 150-220 mmHg without contraindication

Treat to a SBP 140 mmHg Presenting with SBP >220 mmHg

Reasonable for aggressive BP reduction Continuous IV infusion and frequent BP monitoring

INTENSIVE BLOOD-PRESSURE LOWERING IN PATIENTS WITH

ACUTE CEREBRAL HEMORRHAGEQureshi A, Palesch Y, Barsan W, Hanley D, Hsu C, Martin R et al

DESIGN Trial Randomized Multicenter Two-group Open-label

Population (n=1000) Within 4.5 hours of symptom onset >18 years old Glasglow Coma Scale (GCS) >5 Intraparencymal heatoma <60 cm3

Qureshi A et al. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. NEJM

MEASURES Primary Outcomes Proportion of patients having moderately severe-severe disability

Modified Rankin scale score, 4-6 Proportion of patients having died

Secondary Outcomes EQ-5D score Visual-analogue scale (VAS) at 3 months Proportion of patients with a >33% volume increase in hematoma size

Statistical Analysis Proportion of risk

Qureshi A et al. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. NEJM

OUTCOMES

OUTCOMES Primary Outcomes No difference between intensive and standard treatment

Secondary Outcomes No difference between treatment groups

Other Outcomes No differences between groups in rate of death at 3 months post randomization No difference between groups in neurological deterioration at 24 hours post randomization

Qureshi A et al. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. NEJM

ADVERSE EVENTS 72 hours after randomization 1.6% of the intensive treatment group 1.2% of the standard treatment group No significant difference

3 months after randomization 25.6% of the intensive treatment group 20.0% of the standard treatment group No significant difference

Renal Adverse events Significantly higher in the intensive treatment group than standard treatment group

Only significant difference across adverse-event groupsQureshi A et al. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. NEJM

CONCLUSIONS Trial Observations Rate of death or disability at 3 months was much lower than expected based on current literature 37.7% in trial 60% in literature

Trial Conclusions No overall differences between groups Acute reduction to a target systolic blood pressure of 110-139 mmHg not supported

Significant renal adverse events within 7 days of randomization for intensive treatment group

No support for the idea that lowering blood pressure to the above stated range improves functional outcomes for patients with ICHQureshi A et al. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. NEJM

QUESTIONS?

REFERENCES1. My.clevelandclinic.org. 2016 [cited 31 July 2016]. Available from:

http://my.clevelandclinic.org/services/neurological_institute/cerebrovascular-center/diseases-conditions/hic-intracranial-hemorrhage

2. Sacco S, Marini C, Toni D, Olivieri L, Carolei A. Incidence and 10-Year Survival of Intracerebral Hemorrhage in a Population-Based Registry. Stroke. 2008;40(2):394-399.

3. Hemphill J, Greenberg S, Anderson C, Becker K, Bendok B, Cushman M et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. Stroke. 2015;46(7):2032-2060.

4. Qureshi A, Palesch Y, Barsan W, Hanley D, Hsu C, Martin R et al. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. New England Journal of Medicine. 2016;