Early lowering of blood pressure after acute intracerebral haemorrhage: a systematic review and meta-analysis of individual patient data

The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia. Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK. Department of Neurology, Oslo University Hospital, Oslo, Norway. Research and Development Department, The Norwegian Air Ambulance Foundation, Oslo, Norway. Stroke Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK. Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK. National University of Malaysia, Kuala Lumpur, Malaysia. Department of Preventive Medicine and Public Health, Fukuoka University, Fukuoka, Japan. Prince of Wales Clinical School, University of New South Wales, Randwick, New South Wales, Australia. Neurology Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia. Central Clinical School, the University of Sydney, Sydney, New South Wales, Australia. Department of Neurology, Army Hospital Research and Referral, New Delhi, India. Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China. The Shaanxi Cerebrovascular Disease Clinical Research Center, Xi'an, China. Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA. Stroke Research Group, Norfolk and Norwich University Hospital, UK. Norwich Medical School, University of East Anglia, UK. Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO. University of Leicester, Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, Leicester, UK. Department of Neurology and Comprehensive Stroke Center, UCLA, Los Angeles, California, USA. The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia canderson@georgeinstitute.org.au. The George Institute China at Peking University Health Science Center, Beijing, PR China.

Journal of neurology, neurosurgery, and psychiatry. 2021
OBJECTIVE To summarise evidence of the effects of blood pressure (BP)-lowering interventions after acute spontaneous intracerebral haemorrhage (ICH). METHODS A prespecified systematic review of the Cochrane Central Register of Controlled Trials, EMBASE and MEDLINE databases from inception to 23 June 2020 to identify randomised controlled trials that compared active BP-lowering agents versus placebo or intensive versus guideline BP-lowering targets for adults <7 days after ICH onset. The primary outcome was function (distribution of scores on the modified Rankin scale) 90 days after randomisation. Radiological outcomes were absolute (>6 mL) and proportional (>33%) haematoma growth at 24 hours. Meta-analysis used a one-stage approach, adjusted using generalised linear mixed models with prespecified covariables and trial as a random effect. RESULTS Of 7094 studies identified, 50 trials involving 11 494 patients were eligible and 16 (32.0%) shared patient-level data from 6221 (54.1%) patients (mean age 64.2 [SD 12.9], 2266 [36.4%] females) with a median time from symptom onset to randomisation of 3.8 hours (IQR 2.6-5.3). Active/intensive BP-lowering interventions had no effect on the primary outcome compared with placebo/guideline treatment (adjusted OR for unfavourable shift in modified Rankin scale scores: 0.97, 95% CI 0.88 to 1.06; p=0.50), but there was significant heterogeneity by strategy (p(interaction)=0.031) and agent (p(interaction)<0.0001). Active/intensive BP-lowering interventions clearly reduced absolute (>6 ml, adjusted OR 0.75, 95%CI 0.60 to 0.92; p=0.0077) and relative (≥33%, adjusted OR 0.82, 95%CI 0.68 to 0.99; p=0.034) haematoma growth. INTERPRETATION Overall, a broad range of interventions to lower BP within 7 days of ICH onset had no overall benefit on functional recovery, despite reducing bleeding. The treatment effect appeared to vary according to strategy and agent. PROSPERO REGISTRATION NUMBER CRD42019141136.
Study details
Study Design : Systematic Review
Language : eng
Credits : Bibliographic data from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine