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The Magnitude of Blood Pressure Reduction Predicts Poor In-Hospital Outcome in Acute Intracerebral Hemorrhage

An Invited Editorial Commentary to this article was published on 07 July 2020

Abstract

Background

Early systolic blood pressure (SBP) reduction is believed to improve outcome after spontaneous intracerebral hemorrhage (ICH), but there has been a limited assessment of SBP trajectories in individual patients. We aimed to determine the prognostic significance of SBP trajectories in ICH.

Methods

We collected routine data on spontaneous ICH patients from two healthcare systems over 10 years. Unsupervised functional principal components analysis (FPCA) was used to characterize SBP trajectories over first 24 h and their relationship to the primary outcome of unfavorable shift on modified Rankin scale (mRS) at hospital discharge, categorized as an ordinal trichotomous variable (mRS 0–2, 3–4, and 5–6 defined as good, poor, and severe, respectively). Ordinal logistic regression models adjusted for baseline SBP and ICH volume were used to determine the prognostic significance of SBP trajectories.

Results

The 757 patients included in the study were 65 ± 23 years old, 56% were men, with a median (IQR) Glasgow come scale of 14 (8). FPCA revealed that mean SBP over 24 h and SBP reduction within the first 6 h accounted for 76.8% of the variation in SBP trajectories. An increase in SBP reduction (per 10 mmHg) was significantly associated with unfavorable outcomes defined as mRS > 2 (adjusted-OR = 1.134; 95% CI 1.044–1.233, P = 0.003). Compared with SBP reduction < 20 mmHg, worse outcomes were observed for SBP reduction = 40–60 mmHg (adjusted-OR = 1.940, 95% CI 1.129–3.353, P = 0.017) and > 60 mmHg, (adjusted-OR = 1.965, 95% CI 1.011, 3.846, P = 0.047). Furthermore, the association of SBP reduction and outcome varied according to initial hematoma volume. Smaller SBP reduction was associated with good outcome (mRS 0–2) in small (< 7.42 mL) and medium-size (≥ 7.42 and < 30.47 mL) hematomas. Furthermore, while the likelihood of good outcome was low in those with large hematomas (≥ 30.47 mL), smaller SBP reduction was associated with decreasing probability of severe outcome (mRS 5–6).

Conclusion

Our analyses suggest that in the first 6 h SBP reduction is significantly associated with the in-hospital outcome that varies with initial hematoma volume, and early SBP reduction > 40 mmHg may be harmful in ICH patients. For early SBP reduction to have an effective therapeutic effect, both target levels and optimum SBP reduction goals vis-à-vis hematoma volume should be considered.

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Correspondence to Afshin A. Divani.

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Disclosures

Dr. Petersen is supported by the National Science Foundation grant DMS-1811888. Dr. Ziai is supported by grants from the National Institutes of Neurological Disorders and Stroke for other investigations in intracerebral hemorrhage (R01 NS102583, U01 NS080824) and receives consulting fees from C.R. Bard, Inc. both outside of the area of this work. Dr. Moullaali reports grants from the British Heart Foundation and holds a British Heart Foundation clinical research training fellowship. Dr. Anderson has received grant funding from Takeda China, honorarium and travel reimbursement from Boehringer Ingelheim and Amgen, and holds a Senior Principal Research Fellowship and research grants from the National Health and Medical Research Council of Australia. Dr. Suarez is the President of the Neurocritical Care Society, and Chair of the Data Safety Monitoring Board for the INTREPID Study funded by BARD.

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Prior to conducting the study, approval was obtained from the Institutional Review Boards at Hennepin County Medical Center and Fairview Health Services in Minneapolis, MN.

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Divani, A.A., Liu, X., Petersen, A. et al. The Magnitude of Blood Pressure Reduction Predicts Poor In-Hospital Outcome in Acute Intracerebral Hemorrhage. Neurocrit Care 33, 389–398 (2020). https://doi.org/10.1007/s12028-020-01016-z

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Keywords

  • Intracerebral hemorrhage
  • Blood pressure control
  • Blood pressure variability
  • In-hospital outcomes
  • Hematoma volume
  • Computed tomography