The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trial

Code ICH: A Call to Action

“…70 More recently, the INTERACT-3 trial evaluated the effectiveness of a care bundle of intensive BP lowering (target systolic BP <140 mm Hg), correction of hyperglycemia, fever control, and reversal of anticoagulation within 1 hour of emergency department admission in 7036 patients with ICH presenting within 6 hours of onset. 71 The trial used a step-wedge cluster (hospital)randomized trial design in which hospitals successively switched from conventional management to implementation of the care bundle, resulting in an even distribution of patients on completion of the study. The likelihood of poor functional outcome at 6 months evaluated using a modified Rankin Scale shift analysis was lower in the care bundle group (common OR, 0.86 [95% CI, 0.76-0.97]; P=0.015).…”

“…The landmark INTERACT-3 trial now adds further evidence that early intensive BP lowering can reduce the likelihood of poor functional outcome. 71 In patients with ICH, every 1 mL of HE leads to a 5% increase in the odds of death or dependence. 7 This means that HE of 10 mL after baseline CT results in a 55% higher odds of mortality or increased morbidity.…”

Prothrombin Complex Concentrate vs Conservative Management in ICH Associated With Direct Oral Anticoagulants

“…Our results call for timely research in alternative hemostatic therapies for DOAC-associated ICH, especially among Asian patients due to their underrepresentation in the literature, even in a recent trial that evaluated andexanet alfa for factor Xa inhibitor–related ICH with positive preliminary results (NCT03661528). Moreover, with the emergence of medical and neurosurgical management, such as the intensive medical care bundle and minimally invasive hematoma removal, further studies should investigate whether these treatments may benefit patients with DOAC-associated ICH in conjunction with hemostatic agents.…”

Time to Anticoagulation Reversal and Outcomes After Intracerebral Hemorrhage

“…Prior clinical trials of coagulopathy reversal have demonstrated a reduction in ICH expansion and improved clinical outcome . However, there was not sufficient precision or power to establish the presence of a time-dependent effect.…”

“…3,4 Prior clinical trials of coagulopathy reversal have demonstrated a reduction in ICH expansion and improved clinical outcome. 5,6 However, there was not sufficient precision or power to establish the presence of a time-dependent effect. In an observational multicenter study, earlier (less than 4 hours after hospital arrival) reversal of VKA was associated with a significant reduction in ICH expansion and lower in-hospital mortality, but timing of reversal therapy was not assessed.…”