Review of Long-Term Blood Pressure Control After Intracerebral Hemorrhage: Challenges and Opportunities

Abstract

Blood pressure (BP) is the most important modifiable risk factor for intracerebral hemorrhage (ICH). Elevated BP is associated with an increased risk of ICH, worse outcome after ICH, and in survivors, higher risks of recurrent ICH, ischemic stroke, myocardial infarction, and cognitive impairment/dementia. As intensive BP control probably improves the chances of recovery from acute ICH, the early use of intravenous or oral medications to achieve a systolic BP goal of <140 mm Hg within the first few hours of presentation is reasonable for being applied in most patients. In the long-term, oral antihypertensive drugs should be titrated as soon as possible to achieve a goal BP <130/80 mm Hg and again in all ICH patients regardless of age, location, or presumed mechanism of ICH. The degree of sustained BP reduction, rather than the choice of BP-lowering agent(s), is the most important factor for optimizing risk reduction, with varying combinations of thiazide-type diuretics, long-acting calcium channel blockers, ACE (angiotensin-converting enzyme) inhibitors or angiotensin receptor blockers, being the mainstay of therapy. As most patients will require multiple BP-lowering agents, and physician inertia and poor adherence are major barriers to effective BP control, single-pill combination therapy should be considered as the choice of management where available. Increased population and clinician awareness, and innovations to solving patient, provider, and social factors, have much to offer for improving BP control after ICH and more broadly across high-risk groups. It is critical that all physicians, especially those managing ICH patients, emphasize the importance of BP control in their practice.

Focused Update on Vascular Risk and Secondary Prevention in Survivors of Intracerebral Hemorrhage

“…In the majority of ICH survivors, blood pressure remains the most important modifiable risk factor. As Mullen and Anderson 4 summarize in this Focused Update, elevated blood pressure is associated with a continuum of central nervous system and systemic events after an ICH. Blood pressure control is often categorized in terms of the acute emergency or inpatient management and the chronic or outpatient component.…”

Secondary prevention after intracerebral haemorrhage

“…BP-lowering also reduces the risk of ischaemic events and might mitigate the progression of cerebral small vessel disease which contributes to the delayed cognitive impairment and dementia that follow ICH. 24 The Perindopril Protection Against Recurrent Stroke Study (PROGRESS) study and subsequent post-hoc analyses showed that patients with the lowest BP levels during follow-up had the lowest risk of stroke recurrence, both ischaemic and haemorrhagic ones. Strong relationship was found between lower SBP levels and haemorrhagic stroke (P homogeneity = 0.003) with a relative risk reduction of 49% (95% CI, 18%-68%).…”

“…33 BP levels should be assessed regularly in all patients regardless of age, location or presumed small vessel disease underlying the acute ICH. 24 Solid evidence suggests that antiplatelet resumption is safe in the majority of patients with ICH. 34,35 The RESTART trial (Restart or Stop Antithrombotics Randomized Trial) is the only randomized controlled trial that compared the effects of starting or avoiding antiplatelet therapy after ICH.…”

“…In patients with spontaneous ICH, BP control is recommended to prevent haemorrhage recurrence. BP‐lowering also reduces the risk of ischaemic events and might mitigate the progression of cerebral small vessel disease which contributes to the delayed cognitive impairment and dementia that follow ICH 24 . The Perindopril Protection Against Recurrent Stroke Study (PROGRESS) study and subsequent post‐hoc analyses showed that patients with the lowest BP levels during follow‐up had the lowest risk of stroke recurrence, both ischaemic and haemorrhagic ones.…”

“…Guidelines recommend lowering SBP below 130 mm Hg and DBP below 80 mm Hg 33 . BP levels should be assessed regularly in all patients regardless of age, location or presumed small vessel disease underlying the acute ICH 24,26 …”