Rapid BP Lowering Following Intracerebral Hemorrhage

Mark J. Alberts, MD


August 09, 2013

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Hello. I'm Dr. Mark Alberts. I would like to update you on the results of a study called INTERACT2.[1] This study was presented this year at the European Stroke Conference in London and was very recently published in the New England Journal of Medicine.

The purpose of this study was to look for better treatments for patients with intracerebral hemorrhages that are, in most cases, due to hypertension. In the INTERACT2 study, more than 2800 patients were randomly assigned to receive aggressive blood pressure medication in an effort to reach [a target systolic level of] 140 mm Hg or usual therapy to keep the blood pressure in the 140-180 mm Hg systolic range. The primary endpoint was death or major disability, defined as a modified Rankin score of 3-6.

What did the study find? Overall, there was about a 3.5% absolute risk reduction for the primary endpoint in people with aggressive blood pressure treatment vs standard blood pressure therapy. This was very close to being statistically significant, with a P value of .06. The relative risk reduction was about 13%, also in favor of aggressive blood pressure therapy vs standard blood pressure therapy. Interestingly, when you look at other secondary outcomes such as standard of living and activities of daily living, there was also a statistically significant benefit in favor of aggressive blood pressure lowering vs standard therapy. Also, on a hopeful note, there was no evidence of any safety concerns associated with aggressively lowering blood pressure for the vast majority of patients.

What does this mean for active clinicians in the field? What I take from this study is that it is reasonable to treat patients with hypertensive hemorrhages to get their blood pressure down to < 140 mm Hg systolic. There was no dramatic difference in terms of the size of the hematoma or hematoma growth, as was expected in other studies. At the end of the day, it does seem to benefit patients by reducing the rate of death or disability by aggressively lowering blood pressure. It was also very well tolerated.

A parallel study called ATTACH 2 is ongoing in North America, with a similar study design. The results will not be known for another 2-3 years. We will have to see if the guidelines change based on the results of the INTERACT2 study. I think it is reasonable, based on everything that we know, to be a little bit more aggressive and get these patients' blood pressures down to somewhere in the 140 mm Hg range if at all possible. Thank you very much for joining me. Have a good day.


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