Zoekvraag Eva de Jongh Terugrapportage 17 april 2012

Achtergrond  Casus  58-jarige man  Blanco voorgeschiedenis  Presentatie SEH  ICH occipitaal links  RR 240/146 mmHg To treat or not to treat?

Achtergrond  CBO Richtlijn Beroerte, 2008  >60% vd patienten heeft in de acute fase na een ICH een verhoogde bloeddruk.  Vaak spontane bloeddruk daling in de eerste 24 uur.  Behandeling is aangewezen bij een persisterende DBP >120mmHg en een SBP >220mmHg.  Keuze van antihypertensivum

Achtergrond  Kwaliteitsnet: Hypertensieve crisis  Ernstige hypertensie (SBP >220mmHg of DBP >120mmHg) bij intracerebrale bloeding of infarct:  Tensiedaling nastreven binnen 1 uur, langzaam met +/- 15% laten dalen, bij voorkeur met labetolol of nitroprusside.

Zoekvraag  P: spontane intracerebrale bloeding  I:antihypertensiva  C:geen antihypertensiva  O:hematoom neurologische outcome

Zoekstrategie  Search ((((intra cerebral hemorrhage* [tiab]) OR intracerebral hemorrhage* [tiab]) OR (intracerebral haemorrhage* [tiab]) OR (intra cerebral haemorrhage* [tiab]))) AND ((“Antihypertensive Agents “[MESH]) OR (“Antihypertensive Agents”[Pharmacological Action]) OR (anti hyperten* [tiab]) OR (antihyperten* [tiab])))  186 hits  Limits Adult, humans  121 hits

Zoekstrategie  Weinig/geen studies met Rx versus geen Rx.  Voornamelijk observationeel en expert opinion.  Veel verschillende uitkomstmaten.  Geen onderscheid tussen hypertensieve bloeding en reactieve hypertensie bij ICH.

1.  British Journal of Neurosurgery  Blood pressure management in acute intracerebral haemorrhage: low blood pressure and early neurological deterioration  August 2010, Vol. 24, No. 4, Pages  Karuhiro Ohwaki et al.

 Objective: Establish relationship between SBP and early neurological deterioration (END)  Methods:  100 patients with spontaneous ICH with data on minimum SBP in the 24 h after admission.  END diagnosed with GCS score and degree of limb paresis.  Results:  SBP <100mmHg : frequency of END 52%  SBP mmHg: frequency of END 29%  SBP mmHg: frequency of END 14%  SBP >140mmHg: frequency of END 48%

2.  Stroke  Effects of Early Intensive Blood Pressure-Lowering Treatment on the Growth of Hematoma and Perihematomal Edema in Acute Intracerebral Hemorrhage  The Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT)  2010, 41:  Anderson et al.

 Objective: early intensive blood pressure lowering and its effect on hematoma growth.  Methods:  Randomized controlled trial  404 patients, CT-confirmed ICH, elevated SBP.  Intensive (target SBP 140mmHg) vs standard guideline-based management of BP (target SBP 180mmHg).  Baseline and repeat CT’s

Figure 1. Trial profile. Anderson C S et al. Stroke 2010;41: Copyright © American Heart Association

 Results:  Hematoma mean volume (mL)  Na 24 uur: vs  Na 72 uur: vs  Adjusted mean absolute increase (mL)  Baseline to 24 hours:2.40 vs  Baseline to 72 hours:0.15 vs  >72 hours:1.27 vs -1.53

Figure 2. Effects of early treatment to lower BP on absolute (A) and proportional increase (B) in hematoma volume. Anderson C S et al. Stroke 2010;41: Copyright © American Heart Association

Figure 3. Effects of early treatment to lower BP on absolute (A) and proportional increase (B) in perihematomal edema volume. Anderson C S et al. Stroke 2010;41: Copyright © American Heart Association

3.  Archives of neurology  Effect of Systolic Blood pressure reduction on hematoma expansion, perihematomal edema and 3-month outcome among patients with intracerebral hemorrhage.  Results from the Antihypertensive Treatment of Acute Cerebral Hemorrhage Study (ATACH).  Mei 2010; 67 (5):  Qureshi et al.

 Objective: explore relationship between different variables of SBP reduction and hematoma expansion, perihematomal edema and 3-month outcome.  Methods:  patients having ICH with an elevated SBP >170mmHg.  sequentially escalating SBP reduction goals ( , , or mmHg) using iv nicardipine.  Baseline and 24-h CT  Modified Rankin scale score

AHA/ASA Guideline 2010  1. If SBP is >200 mm Hg or MAP is >150 mm Hg, then consider aggressive reduction of BP with continuous intravenous infusion.  2. If SBP is >180 mm Hg or MAP is >130 mm Hg and there is the possibility of elevated ICP, then consider monitoring ICP and reducing BP using intermittent or continuous intravenous medications while maintaining a cerebral perfusion pressure ≥60 mm Hg.  3. If SBP is >180 mm Hg or MAP is >130 mm Hg and there is not evidence of elevated ICP, then consider a modest reduction of BP (eg, MAP of 110 mm Hg or target BP of 160/90 mm Hg) using intermittent or continuous intravenous medications to control BP.

Future research  The intracerebral Haemorrhage Acutely Decreasing Arterial Pressure Trial: ICH ADAPT.  Acute ICH, onset within 24 hours, systolic BP >150 mmHg  Randomization  Target SBP <150mmHg (iv labetolol/hydralazine/enalapril)  Target SBP 180mmHg)  CT perfusion scan (2 hours after randomization)  CT scan (24 hours after randomization)  Day 30: NIHSS, modified Rankin Score, Barthel Index  Day 90: NIHSS, modified Rankin Score, Barthel Index

 The second (main) phase of an open, randomised, multicentre study to investigate the effectiveness of an intensive blood pressure reduction in acute cerebral haemorrhage trial (INTERACT 2).  Acute ICH and SBP >150mmHg (2800 subjects)  Randomization  Target SBP <140mmHg  Target SBP <180mmHg  Combined endpoint of death and dependency according to the modified Rankin Scale at 90 days.

Conclusie  Studies met beperkte lange termijn resultaten  Bewijs in de richting van intensieve bloeddruk verlaging  Aanpassing CBO richtlijn?