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Adherence to Established Blood Pressure Targets and Associated Complications in Patients Presenting with Acute Intracerebral Hemorrhage

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Abstract

Background

Conflicting evidence exists surrounding systolic blood pressure (SBP) control in patients with acute intracerebral hemorrhage (ICH). The 2022 American Heart Association and American Stroke Association guidelines recommend targeting a SBP of 140 mm Hg while maintaining the range of 130–150 mm Hg. The current practice at our health system is to titrate antihypertensives to a SBP goal of < 160 mm Hg, which aligns with previous recommendations. We hypothesized that the prior lack of guidance to a specific SBP target range predisposed patients to hypotension leading to an increased risk of brain and renal adverse events.

Methods

This retrospective, multicenter, single health system cohort study included adults admitted to the neurointensive care unit or intermediate unit with acute ICH from June 2019 to June 2021. The primary objective evaluated the frequency of time within SBP range (140–160 mm Hg) in the first 48 h. Secondary and safety end points included the frequency of time above and below the established SBP range, episodes of hypotension (defined as a decrease in SBP < 140 mm Hg prompting discontinuation in antihypertensive[s] or the initiation of vasopressor[s]), the incidence of new brain or renal adverse events within 7 days, and modified Rankin Scale at discharge.

Results

A total of 80 patients (59% men; median age 62 years) were included. The majority of ICHs in this cohort were intraparenchymal (70%). Nearly one third were attributed to systemic hypertension (31%). During the first 48 h of admission, the frequency of time spent above, within, and below the target SBP range were 6 h (12%), 16 h (34%), and 26 h (54%), respectively. Hypotension was associated with renal adverse events (odds ratio [OR] 3.36, 95% confidence interval [CI] 1.10–11.44, p = 0.023). A relative SBP reduction > 20% in the first 48 h was associated with renal adverse events (OR 8.99, 95% CI 2.57–35.25, p < 0.001), brain ischemia (OR 22.5, 95% CI 1.92–300.11, p = 0.005), and an increased odd of a modified Rankin Scale of 4–6 at discharge (OR 11.79, 95% CI 2.79–57.02, p < 0.001).

Conclusions

In individuals with nontraumatic/nonaneurysmal ICH, SBP measurements were observed to be < 140 mm Hg for > 50% of the initial 48 h following admission. Hypotension and relative SBP reduction > 20% were also independent predictors of renal adverse events. SBP reduction > 20% was also an independent predictor of brain ischemia. These data indicate that intensive SBP reduction following ICH predispose patients to secondary organ injury that may impact long-term outcomes. Our data suggest that a more modest lowering of the SBP within 48 h, as recommended in the most recent guidelines, may minimize the risk of further adverse events.

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Authors and Affiliations

  1. Department of Pharmacy, Northwestern Memorial Hospital, 251 E. Huron St., Chicago, IL, 60611, USA

    Nicole A. Leshko

  2. Department of Pharmacy, Penn Presbyterian Medical Center, 51 N. 39th St, Philadelphia, PA, 19104, USA

    Raymond F. Lamore, Megan K. Zielke & Lauren E. Schmidt

  3. Department of Neurology, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, 19104, USA

    Danielle K. Sandsmark

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  1. Nicole A. Leshko
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  2. Raymond F. Lamore
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  5. Lauren E. Schmidt
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Contributions

Conceptualization: RL, MZ, and LS. Data curation: LS. Formal analysis: NL, RL, MZ, and LS. Funding acquisition: None. Investigation: NL. Methodology: NL, RL, MZ, and LS. Project administration: NL, RL, MZ, and LS. Resources: None. Software: None. Supervision: DS and LS. Validation: NL, RL, MZ, DS, and LS. Visualization: NL, RL, MZ, DS, and LS. Writing (original draft): NL, RL, MZ, and LS. Writing (review & editing): NL, RL, MZ, DS, and LS. All authors approve of the final manuscript.

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Correspondence to Nicole A. Leshko.

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This study was approved by the institutional review board of the University of Pennsylvania.

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Leshko, N.A., Lamore, R.F., Zielke, M.K. et al. Adherence to Established Blood Pressure Targets and Associated Complications in Patients Presenting with Acute Intracerebral Hemorrhage. Neurocrit Care 39, 378–385 (2023). https://doi.org/10.1007/s12028-023-01679-4

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