By Matthew E. Fink, MD
Professor and Chairman, Department of Neurology, Weill Cornell Medical College; Neurologist-in-Chief, New York Presbyterian Hospital
Dr. Fink reports he is a retained consultant for Procter & Gamble and Pfizer.
SOURCE: Qureshi AI, Palesch YY, Barsan WG, et al for the ATTACH-2 Trial Investigators. Intensive blood-pressure lowering in patients with acute cerebral hemorrhage. N Engl J Med 2016; DOI: 10.1056/NEJMoa1603460 [Epub ahead of print].
The hypertensive response following an instance of spontaneous intracerebral hemorrhage may be linked to hematoma expansion and increased risk of mortality. The INERACT-2 study, published in the New England Journal of Medicine, examined the effectiveness of blood pressure reduction to target systolic pressure of less than 140 mmHg following six hours of hemorrhage onset. The study concluded without finding a significant difference in mortality or neurological outcomes between relevant patients with target systolic blood pressure of less than 140 mmHg or those with a target systolic pressure of less than 180 mmHg. As a follow-up, the ATTACH-2 study was conducted to determine the effectiveness of more rapid blood pressure lowering: enacted within 4.5 hours of symptom onset, with a target systolic pressure of less than 120 mmHg. The study measured and compared rates of death and disability at the three-month benchmark among patients subjected to blood pressure lowering after spontaneous intracerebral hemorrhage.
The 1000 participating patients were evenly divided between either the standard treatment group or the intensive treatment group. Further enrollment was halted after interim analysis proved unfruitful. Final analysis showed that there were not significant differences between the rates of death/disability among the standard treatment (37.7%) and intensive treatment groups (38.7%) at the three-month benchmark. These findings came after taking account of age adjustments, initial Glasgow Coma Scale score, the presence of intraventricular hemorrhage and various other premorbid considerations. Despite non-significant differences in rates of death and disability, the intensive treatment group demonstrated a significantly higher rate of renal complications and adverse renal events within the first week following randomization and treatment. The authors conclude by asserting that intensive treatment of intracerebral hemorrhage patients to achieve a target systolic blood pressure under 120 mmHg does not result in lower rates of disability or mortality than standard treatment, but can result in increased risk for renal complications.