By Matthew E. Fink, MD

Professor and Chairman, Department of Neurology, Weill Cornell Medical College; Neurologist-in-Chief, New York Presbyterian Hospital

Dr. Fink reports he is a retained consultant for Procter & Gamble and Pfizer.

SOURCE: Qureshi AI, Palesch YY, Barsan WG, et al for the ATTACH-2 Trial Investigators. Intensive blood-pressure lowering in patients with acute cerebral hemorrhage. N Engl J Med 2016; DOI: 10.1056/NEJMoa1603460 [Epub ahead of print].

After spontaneous intracerebral hemorrhage, there is a severe hypertensive response that may be associated with hematoma expansion and increased mortality. The INERACT-2 study (N Engl J Med 2013;368:2355-2365) looked at the effectiveness of blood pressure reduction within six hours after symptom onset, to a target systolic blood pressure of < 140 mmHg. There was no significant difference in neurological outcome or mortality, compared to patients who were treated with a target systolic blood pressure of < 180 mmHg. The ATTACH-2 trial was designed to determine if even more rapid lowering of blood pressure, within 4.5 hours of onset of symptoms, and a target blood pressure of < 120 mmHg, would result in an improved rate of death or disability at three months.

Of 1,000 participants with a mean systolic blood pressure of 200 ± 27 mmHg at baseline, 500 were assigned to intensive treatment and 500 to standard treatment. Enrollment was stopped because of futility after an interim analysis. The primary outcome of death or disability was observed in 38.7% of the participants in the intensive treatment group and 37.7% of participants in the standard treatment group, after adjustment for age, initial Glasgow Coma Scale score, presence or absence of intraventricular hemorrhage, and other premorbid factors. The rate of renal adverse events, within seven days after randomization, were significantly higher in the intensive treatment group than in the standard treatment group. In conclusion, intensive treatment of patients with intracerebral hemorrhage to achieve a target systolic blood pressure < 120 mmHg did not result in a lower rate of death or disability, but did result in an increased rate of renal adverse events.