Skip to main content
SpringerLink
Log in

The Unsolved Conundrum of Optimal Blood Pressure Target During Acute Haemorrhagic Stroke: A Comprehensive Analysis

  • Review Article
  • Published:
High Blood Pressure & Cardiovascular Prevention Aims and scope Submit manuscript

Abstract

Intracerebral haemorrhage (ICH) is a devastating cerebrovascular disease, which accounts to 15% of all strokes. Among modifiable risk factors for ICH, hypertension is the most frequent. High blood pressure (BP) is detected in more than 75–80% of patients with ICH. Extremely elevated BP has been associated with early hematoma growth, a relatively frequent occurrence and powerful predictor of poor outcome in patients with spontaneous ICH. On the other hand, excessively low BP might cause cerebral hypoperfusion and ultimately lead to poor outcome. This review will analyse the most important trials that have tried to establish how far should BP be lowered during acute ICH. These trials have demonstrated either a small non-significant benefit (INTERACT-2, INTEnsive blood pressure Reduction in Acute Cerebral haemorrhage Trial) or no benefit (ATACH-2, Antihypertensive treatment of acute cerebral haemorrhage II study) when intensive systolic BP reduction was compared with modest or standard BP reduction. The more recent meta-analyses including studies investigating this issue yielded similar conclusions: aggressive BP control in the acute phase of ICH is not beneficial. For these reasons the 2018 European Society of Cardiology/ European Society of Hypertension Guidelines for the management of arterial hypertension, do not recommend treatment to immediately lower BP in patients with acute ICH and systolic BP < 220 mmHg. Careful lowering of SBP to less than 180 mmHg via i.v. Infusion may be considered only in patients with SBP ≥ 220 mmHg.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Adapted from Ref. [8]

Fig. 2

Adapted from Ref. [9]

Similar content being viewed by others

References

  1. Galassi FM, Habicht ME, Rühli FJ, De Carolis S. A unique case of stroke and upper limb paralysis in a mid-18th century natural mummy. Circ Res. 2017;121:338–40. https://doi.org/10.1161/circresaha.117.311427.

    Article  CAS  PubMed  Google Scholar 

  2. Katan M, Luft A. Global burden of stroke. Semin Neurol. 2018;38:208–11. Available from: http://www.thieme-connect.de/DOI/DOI?10.1055/s-0038-1649503.

  3. Gale CP, Casadei B. Death from stroke in Europe: if you can’t measure it, you can’t improve it. Eur Heart J. 2018. https://doi.org/10.1093/eurheartj/ehy543 (EPub ahead of print).

  4. Pistoia F, Sacco S, Degan D, Tiseo C, Ornello R, Carolei A. Hypertension and stroke: epidemiological aspects and clinical evaluation. High Blood Press Cardiovasc Prev. 2016;23:18–23. https://doi.org/10.1007/s40292-015-0115-2.

    Article  Google Scholar 

  5. Shah R, Wilkins E, Nichols M, Kelly P, El-Sadi F, Wright FL, Townsend N. Epidemiology report: trends in sex-specific cerebrovascular disease mortality in Europe based on WHO mortality data. Eur Heart J. 2018. https://doi.org/10.1093/eurheartj/ehy378 (Epub ahead of print).

  6. Kim BJ, Bae HJ, Wong L. Pathophysiology and mechanisms whereby hypertension may cause stroke. In: Aiyagari V, Gorelick P, editors. Hypertension and stroke, clinical hypertension and vascular diseases. Cham: Springer International Publishing AG Switzerland; 2016. p. 109–28.

    Google Scholar 

  7. Carnevale D, Lembo G. Hypertension and cerebrovascular dysfunction acute and chronic brain pathological alterations. High Blood Press Cardiovasc Prev. 2010;17:191–200. https://doi.org/10.2165/11311950-000000000-00000.

    Article  CAS  Google Scholar 

  8. O’Donnell MJ, Chin SL, Rangarajan S, Xavier D, Liu L, Zhang H, Rao-Melacini P, Zhang X, Pais P, Agapay S, Lopez-Jaramillo P, Damasceno A, Langhorne P, McQueen MJ, Rosengren A, Dehghan M, Hankey GJ, Dans AL, Elsayed A, Avezum A, Mondo C, Diener HC, Ryglewicz D, Czlonkowska A, Pogosova N, Weimar C, Iqbal R, Diaz R, Yusoff K, Yusufali A, Oguz A, Wang X, Penaherrera E, Lanas F, Ogah OS, Ogunniyi A, Iversen HK, Malaga G, Rumboldt Z, Oveisgharan S, Al Hussain F, Magazi D, Nilanont Y, Ferguson J, Pare G, Yusuf S, INTERSTROKE investigators. Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-control study. Lancet. 2016;388:761–75. https://doi.org/10.1016/s0140-6736(16)30506-2.

    Article  PubMed  Google Scholar 

  9. Rapsomaniki E, Timmis A, George J, Pujades-Rodriguez M, Shah AD, Denaxas S, White IR, Caulfield MJ, Deanfield JE, Smeeth L, Williams B, Hingorani A, Hemingway H. Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1 25 million people. Lancet. 2014;383:1899–911. https://doi.org/10.1016/s0140-6736(14)60685-1.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Salvetti M, Paini A, Bertacchini F, Aggiusti C, Stassaldi D, Verzeri L, Saccà G, Muiesan ML. Therapeutic approach to hypertensive emergencies: hemorrhagic stroke. High Blood Press Cardiovasc Prev. 2018;25:191–5. https://doi.org/10.1007/s40292-018-0262-3.

    Article  CAS  PubMed  Google Scholar 

  11. Anderson CS, Huang Y, Wang JG, Arima H, Neal B, Peng B, Heeley E, Skulina C, Parsons MW, Kim JS, Tao QL, Li YC, Jiang JD, Tai LW, Zhang JL, Xu E, Cheng Y, Heritier S, Morgenstern LB, Chalmers J, INTERACT Investigators. Intensive blood pressure reduction in acute cerebral haemorrhage trial (INTERACT): a randomised pilot trial. Lancet Neurol. 2008;7:391–9. https://doi.org/10.1016/s1474-4422(08)70069-3.

    Article  PubMed  Google Scholar 

  12. Anderson CS, Heeley E, Huang Y, Wang J, Stapf C, Delcourt C, Lindley R, Robinson T, Lavados P, Neal B, Hata J, Arima H, Parsons M, Li Y, Wang J, Heritier S, Li Q, Woodward M, Simes RJ, Davis SM, Chalmers J, INTERACT2 Investigators. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013;368:2355–65. https://doi.org/10.1056/nejmoa1214609.

    Article  CAS  PubMed  Google Scholar 

  13. Butcher KS, Jeerakathil T, Hill M, Demchuk AM, Dowlatshahi D, Coutts SB, Gould B, McCourt R, Asdaghi N, Findlay JM, Emery D, Shuaib A, ICH ADAPT Investigators. The intracerebral hemorrhage acutely decreasing arterial pressure trial. Stroke. 2013;44:620–6. https://doi.org/10.1161/strokeaha.111.000188.

    Article  PubMed  Google Scholar 

  14. Tsivgoulis G, Katsanos AH, Butcher KS, Boviatsis E, Triantafyllou N, Rizos I, Alexandrov AV. Intensive blood pressure reduction in acute intracerebral hemorrhage: a meta-analysis. Neurology. 2014;83:1523–9. https://doi.org/10.1212/WNL.0000000000001696.

    Article  PubMed  Google Scholar 

  15. Qureshi AI, Palesch YY, Barsan WG, Hanley DF, Hsu CY, Martin RL, Moy CS, Silbergleit R, Steiner T, Suarez JI, Toyoda K, Wang Y, Yamamoto H, Yoon BW, ATACH-2 Trial Investigators and the Neurological Emergency Treatment Trials Network. Intensive blood-pressure lowering in patients with acute cerebral hemorrhage. N Engl J Med. 2016;375:1033–43. https://doi.org/10.1056/nejmoa1603460.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Lattanzi S, Cagnetti C, Provinciali L, Silvestrini M. How should we lower blood pressure after cerebral hemorrhage? A systematic review and meta-analysis. Cerebrovasc Dis. 2017;43:207–13. https://doi.org/10.1159/000462986.

    Article  PubMed  Google Scholar 

  17. Shi L, Xu S, Zheng J, Xu J, Zhang J. Blood pressure management for acute intracerebral hemorrhage: a meta-analysis. Sci Rep. 2018;7:14345. https://doi.org/10.1038/s41598-017-13111-x.

    Article  CAS  Google Scholar 

  18. Gong S, Lin C, Zhang D, Kong X, Chen J, Wang C, Li Z, Chen R, Sheng P, Dong Y, Hou L. Effects of intensive blood pressure reduction on acute intracerebral hemorrhage: a systematic review and meta-analysis. Sci Rep. 2017;7:10694. https://doi.org/10.1038/s41598-017-10892-z.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Boulouis G, Morotti A, Goldstein JN, Charidimou A. Intensive blood pressure lowering in patients with acute intracerebral haemorrhage: clinical outcomes and haemorrhage expansion. Systematic review and meta-analysis of randomised trials. J Neurol Neurosurg Psychiatry. 2017;88:339–45. https://doi.org/10.1136/jnnp-2016-315346.

    Article  PubMed  Google Scholar 

  20. Carandini T, Bozzano V, Scarpini E, Montano N, Solbiati M. Intensive versus standard lowering of blood pressure in the acute phase of intracranial haemorrhage: a systematic review and meta-analysis. Intern Emerg Med. 2018;13:95–105. https://doi.org/10.1007/s11739-017-1716-7.

    Article  PubMed  Google Scholar 

  21. Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, Clement DL, Coca A, de Simone G, Dominiczak A, Kahan T, Mahfoud F, Redon J, Ruilope L, Zanchetti A, Kerins M, Kjeldsen SE, Kreutz R, Laurent S, Lip GYH, McManus R, Narkiewicz K, Ruschitzka F, Schmieder RE, Shlyakhto E, Tsioufis C, Aboyans V, Desormais I, Authors/Task Force Members. ESC/ESH Guidelines for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension. J Hypertens. 2018;36:1953–2041. https://doi.org/10.1097/hjh.0000000000001940.

    Article  CAS  PubMed  Google Scholar 

  22. van den Born BH, Lip GYH, Brguljan-Hitij J, Cremer A, Segura J, Morales E, Mahfoud F, Amraoui F, Persu A, Kahan T, Agabiti Rosei E, de Simone G, Gosse P, Williams B. ESC Council on hypertension position document on the management of hypertensive emergencies. Eur Heart J Cardiovasc Pharmacother [Internet]. 2018; Available from: https://academic.oup.com/ehjcvp/advance-article/doi/10.1093/ehjcvp/pvy032/5079054.

Download references

Author information

Authors and Affiliations

  1. Unit of Nephrology and Hypertension, Dipartimento Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza (PROMISE), European Society of Hypertension Excellence Centre, Piazza delle Cliniche, 2, 90146, Palermo, Italy

    Giuseppe Mulè, Alessandra Sorce, Marta Giambrone, Santina Cottone & Giovanni Cerasola

  2. Stroke Unit, Dipartimento di Biomedicina sperimentale e Neuroscienze cliniche, Università di Palermo, Palermo, Italy

    Brigida Fierro

Authors
  1. Giuseppe Mulè
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Alessandra Sorce
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Marta Giambrone
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Brigida Fierro
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Santina Cottone
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Giovanni Cerasola
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Giuseppe Mulè.

Ethics declarations

Conflict of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Mulè, G., Sorce, A., Giambrone, M. et al. The Unsolved Conundrum of Optimal Blood Pressure Target During Acute Haemorrhagic Stroke: A Comprehensive Analysis. High Blood Press Cardiovasc Prev 26, 119–126 (2019). https://doi.org/10.1007/s40292-019-00305-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40292-019-00305-9

Keywords

Search

Navigation