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Intensive blood pressure lowering in patients with acute intracerebral haemorrhage: clinical outcomes and haemorrhage expansion. Systematic review and meta-analysis of randomised trials
  1. Gregoire Boulouis1,2,3,
  2. Andrea Morotti1,2,
  3. Joshua N Goldstein1,2,4,
  4. Andreas Charidimou1,2
  1. 1 Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, Massachusetts, USA
  2. 2 Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
  3. 3 Department of Neuroradiology, Centre Hospitalier Sainte-Anne, Université Paris-Descartes, INSERM UMR 894, Paris, France
  4. 4 Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
  1. Correspondence to Andreas Charidimou, Harvard Medical School, J. Kistler Stroke Research Center, Massachusetts General Hospital, 175 Cambridge st, Suite 300, Boston, MA 02114, USA ; andreas.charidimou.09{at}ucl.ac.uk

Abstract

Introduction It is unclear whether intensive lowering of blood pressure (BP) at the acute phase of intracerebral haemorrhage (ICH) is beneficial. We performed a meta-analysis of randomised controlled trials (RCTs) to assess whether intensive BP lowering in patients with acute ICH is safe and effective in improving clinical outcomes.

Methods We searched PubMed, EMBASE and the Cochrane databases for relevant RCTs and calculated pooled OR for 3-month mortality (safety outcome) and 3-month death or dependency (modified Rankin Scale (mRs) ≥3;efficacy outcome), in patients with acute ICH randomised to either intensive BP-lowering or standard BP-lowering treatment protocols. We also investigated the association between treatment arm and ICH expansion at 24 hours. Random effects models with DerSimonian-Laird weights were used.

Results Five eligible studies including 4360 patients with acute ICH were pooled in meta-analysis. The risk of 3-month mortality was similar between patients randomised to intensive BP-lowering treatment and standard BP-lowering treatment (OR: 0.99; 95% CI: 0.82 to 1.20, p=0.909). Intensive BP-lowering treatment showed a (non-significant) trend for an association with lower 3-month death or dependency risk compared with standard treatment (OR: 0.91; 95% CI: 0.80 to 1.02), p=0.106). Intensive BP reduction was associated with a trend for lower risk of significant ICH expansion compared with standard treatment (OR: 0.82; 95% CI: 0.68 to 1.00, p=0.056), especially in larger RCTs.

Conclusions For patients with acute ICH similar to those included in RCTs and without contraindication to acute BP treatment, intensive acute BP lowering is safe, but does not seem to provide an incremental clinical benefit in terms of functional outcomes. The effect of intensive BP lowering on significant haematoma expansion at 24 hours warrants further investigation.

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Footnotes

  • Funding GB was supported by a Fulbright Research Grant, a Monahan Foundation Research Grant and a Philippe Foundation Grant. The study was supported by a NIH/NINDS grant 5R01NS073344.

  • Competing interests JNG received research funding from NIH/NINDS 5R01NS073344, Boehringer-Ingelheim, Pfizer and Portola.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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