TY - JOUR
T1 - Association of Intensive Blood Pressure Reduction with Risk of Hematoma Expansion in Patients with Deep Intracerebral Hemorrhage
AU - Leasure, Audrey C.
AU - Qureshi, Adnan I.
AU - Murthy, Santosh B.
AU - Kamel, Hooman
AU - Goldstein, Joshua N.
AU - Woo, Daniel
AU - Ziai, Wendy C.
AU - Hanley, Daniel F.
AU - Al-Shahi Salman, Rustam
AU - Matouk, Charles C.
AU - Sansing, Lauren H.
AU - Sheth, Kevin N.
AU - Falcone, Guido J.
N1 - Funding Information:
reported grants from the American Heart Association and grants from the National Institutes of Health during the conduct of the study. Dr Murthy reported grants from the National Institute of Neurological Disorders and Stroke and grants from Leon Levy Foundation outside the submitted work. Dr Goldstein reported personal fees from CSL Behring and Octapharma, nonfinancial support from Pfizer, and other support from Philips Healthcare outside the submitted work. Dr Woo reported grants from the National Institutes of Health during the conduct of the study. Dr Ziai reported grants from the National Institutes of Health and personal fees from C. R. Bard Inc and Headsense Inc outside the submitted work. Dr Hanley reported grant funding from the National Institutes of Health (grant U01NS062091) during the conduct of the study and personal fees from BrainScope, Neurotrope, Op2Lysis, Portola Pharmaceuticals, and Medtronic outside the submitted work. Dr Al-Shahi Salman reported grants from the British Heart Foundation, the Stroke Association, and Chest Heart & Stroke Scotland outside the submitted work. Dr Sansing reported grants from the National Institute of Neurological Disorders and Stroke and personal fees from Genentech outside the submitted work. Dr Sheth reported grants from the National Institutes of Health, American Heart Association, Bard, Novartis, and Hyperfine outside the submitted work. No other disclosures were reported.
Funding Information:
Funding/Support: This study is supported by the
Publisher Copyright:
© 2019 American Medical Association. All rights reserved.
PY - 2019/8
Y1 - 2019/8
N2 - Importance: Hypertension is the strongest risk factor for spontaneous intracerebral hemorrhage (ICH) involving deep brain regions, but it appears to be unknown if intensive blood pressure reduction in the acute care setting decreases hematoma expansion or improves outcomes in patients with deep ICH. Objective: To determine whether intensive blood pressure reduction is associated with decreased risk of hematoma expansion and changes in 90-day modified Rankin Scale scores and if these associations are modified by the specific deep-brain nuclei involved. Design, Setting, and Participants: This study is an exploratory analysis of the Antihypertensive Treatment of Acute Cerebral Hemorrhage-2 international, multicenter randomized clinical trial, which was conducted from May 2011 to September 2015, enrolled eligible patients with primary ICH, and followed up with them for 90 days. Patients who had ICH and complete neuroimaging data were included in the analysis. Data analysis was completed from July 2018 to December 2018. Exposures: Participants were randomized to either intensive treatment (with a systolic blood pressure target of 110-139 mm Hg) or standard treatment (with a systolic blood pressure target of 140-179 mm Hg). Main Outcomes and Measures: The main outcome was hematoma expansion, defined as an increase greater than 33% in hematoma volume between baseline and 24 hours. Functional outcome was evaluated 90 days after the ICH via the modified Rankin Scale. Results: Of 1000 trial participants, 870 (87.0%) had deep ICH, of whom 780 (89.7%) had complete neuroimaging data (of 336 thalamic and 444 basal ganglia hemorrhages). The baseline characteristics of the intensive and standard treatment groups remained balanced in this subgroup of the original study. Intensive treatment was associated with a decreased risk of hematoma expansion in univariable analysis (odds ratio [OR], 0.62 [95% CI, 0.43-0.87]; P =.006) and multivariable analysis (OR, 0.61 [95% CI, 0.42-0.88]; P =.009). This association was modified by the specific deep location of the ICH (OR, 0.44 [95% CI, 0.22-0.96]; interaction P =.02), with stratified analyses showing a reduction in risk of hematoma expansion with intensive vs standard treatment among basal ganglia ICH (OR, 0.44 [95% CI, 0.27-0.72]; P =.001) but not thalamic ICH (OR, 0.91 [95% CI, 0.51-0.64]; P =.76). Intensive treatment was not associated with an improvement in the modified Rankin Scale score distribution. Conclusions and Relevance: Compared with standard treatment, intensive blood pressure treatment was associated with reduced hematoma expansion in deep ICH, specifically among basal ganglia hemorrhages.
AB - Importance: Hypertension is the strongest risk factor for spontaneous intracerebral hemorrhage (ICH) involving deep brain regions, but it appears to be unknown if intensive blood pressure reduction in the acute care setting decreases hematoma expansion or improves outcomes in patients with deep ICH. Objective: To determine whether intensive blood pressure reduction is associated with decreased risk of hematoma expansion and changes in 90-day modified Rankin Scale scores and if these associations are modified by the specific deep-brain nuclei involved. Design, Setting, and Participants: This study is an exploratory analysis of the Antihypertensive Treatment of Acute Cerebral Hemorrhage-2 international, multicenter randomized clinical trial, which was conducted from May 2011 to September 2015, enrolled eligible patients with primary ICH, and followed up with them for 90 days. Patients who had ICH and complete neuroimaging data were included in the analysis. Data analysis was completed from July 2018 to December 2018. Exposures: Participants were randomized to either intensive treatment (with a systolic blood pressure target of 110-139 mm Hg) or standard treatment (with a systolic blood pressure target of 140-179 mm Hg). Main Outcomes and Measures: The main outcome was hematoma expansion, defined as an increase greater than 33% in hematoma volume between baseline and 24 hours. Functional outcome was evaluated 90 days after the ICH via the modified Rankin Scale. Results: Of 1000 trial participants, 870 (87.0%) had deep ICH, of whom 780 (89.7%) had complete neuroimaging data (of 336 thalamic and 444 basal ganglia hemorrhages). The baseline characteristics of the intensive and standard treatment groups remained balanced in this subgroup of the original study. Intensive treatment was associated with a decreased risk of hematoma expansion in univariable analysis (odds ratio [OR], 0.62 [95% CI, 0.43-0.87]; P =.006) and multivariable analysis (OR, 0.61 [95% CI, 0.42-0.88]; P =.009). This association was modified by the specific deep location of the ICH (OR, 0.44 [95% CI, 0.22-0.96]; interaction P =.02), with stratified analyses showing a reduction in risk of hematoma expansion with intensive vs standard treatment among basal ganglia ICH (OR, 0.44 [95% CI, 0.27-0.72]; P =.001) but not thalamic ICH (OR, 0.91 [95% CI, 0.51-0.64]; P =.76). Intensive treatment was not associated with an improvement in the modified Rankin Scale score distribution. Conclusions and Relevance: Compared with standard treatment, intensive blood pressure treatment was associated with reduced hematoma expansion in deep ICH, specifically among basal ganglia hemorrhages.
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U2 - 10.1001/jamaneurol.2019.1141
DO - 10.1001/jamaneurol.2019.1141
M3 - Article
C2 - 31081862
AN - SCOPUS:85065591224
VL - 76
SP - 949
EP - 955
JO - JAMA Neurology
JF - JAMA Neurology
SN - 2168-6149
IS - 8
ER -