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FACP. Colegio de médicos de Tarragona Nº 4305520 / fgcapriles@gmail.com

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viernes, 5 de agosto de 2016

Intensive Blood Pressure Control in ACH

ATACH-2
R.E.B.E.L.EM - Posted by Anand Swaminathan - Aug 4, 2016
Background: Hemorrhagic stroke accounts for only 11-22% of all strokes but up to 50% of all stroke mortality. Additionally, there is significant disability associated with the disease in survivors. Much of our attention in the Emergency Department (ED) is guided towards preventing expansion of bleeding and secondary injury after the initial insult. Physiologically, controlling blood pressure has always appeared to be a reasonable goal as it may decrease hematoma expansion and thus mortality. However, there is little high-quality evidence to guide clinicians in determining what the goal blood pressure should be and whether there’s truly a patient centered benefit to aggressive blood pressure management. The recently published INTERACT-2 trial demonstrated no benefit for death or disability for aggressive blood pressure control when started within 6 hours of symptom onset (though the authors touted benefits seen only after ordinal analysis) but some critics have argued that treatment should be started earlier.
Author’s conclusions: “The treatment of participants with intracerebral hemorrhage to achieve a target systolic blood pressure of 110 to 139 mm Hg did not result in a lower rate of death or disability than standard reduction to a target of 140 to 179 mm Hg.”
Our Conclusion: Intensive blood pressure control (SBP 110-139 mm Hg) in patients with intracerebral hemorrhage does not improve 90 day death or disability (mRS 4-6) in comparison to standard management.
Potential Impact to Current Practice:
This study confirms the negative findings seen in the INTERACT-2 trial that aggressive control of blood pressure in patients with intracerebral hemorrhage does not improve outcomes. Based on current evidence, intensive blood pressure reduction should not be pursued.
Clinical Bottom Line:
There does not appear to be a benefit to aggressive blood pressure reduction in patients with intracerebral hemorrhage. Standard therapy aimed at SBP < 180 mm Hg should be pursued in most patients.