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Chambergo-Michilot D, Brañez-Condorena A, Alva-Diaz C, Sequeiros J, Abanto C, Pacheco-Barrios K. Evidence-based appraisal of blood pressure reduction in spontaneous intracerebral hemorrhage: A scoping review and overview. Clin Neurol Neurosurg 2021; 202:106497. [PMID: 33517161 DOI: 10.1016/j.clineuro.2021.106497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/09/2021] [Accepted: 01/11/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND AIM There is a current debate on the best approach for blood pressure (BP) reduction in patients with spontaneous intracerebral hemorrhage (ICH). Through this scoping review, we aimed to examine how research on reducing BP in ICH patients has been conducted and to clarify the evidence on which approach is the best (intensive vs. standard BP reductions). METHODS We performed a scoping review and overview of reviews of the literature. We systematically searched clinical practice guidelines (CPGs), systematic reviews (SRs), and randomized controlled trials (RCTs) that compared intensive versus standard BP reduction. We searched in three databases from inception until March 2020. Two independent authors conducted the study selection, data extraction, quality assessment, and overlapping analysis of SRs. We performed a description and critical appraisal of the current body of evidence. RESULTS We included three CPGs (with moderate to high quality); all of them recommended intensive reduction in specific clinical settings. We included eight SRs (with high overlap and critically low quality): two supported intensive reduction and four supported its safety, but not effectiveness. One SR reported that patients with intensive reduction had a significant risk of renal adverse events. We included seven RCTs (with limitations in randomization process); trials with large population did not found significant differences in mortality and disability. One RCT reported a significantly higher number of renal adverse events. CONCLUSIONS CPGs support the use of intensive BP reduction; however, most recent SRs partially supported or did not support it due to the association with renal events. It seems the range goal between 140 and 180 mmHg could be safe and equally effective than intensive reduction. We recommend further research in serious and non-serious events promoted by intensive reduction and outcomes homogenization across studies to ensure correct comparison.
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Affiliation(s)
- Diego Chambergo-Michilot
- Escuela de Medicina Humana, Facultad de Ciencias de la Salud, Universidad Científica del Sur, Lima, Peru; Department of Cardiology Research, Torres de Salud National Research Center, Lima, Peru; Red Latinoamericana de Cardiología, Lima, Peru.
| | - Ana Brañez-Condorena
- Asociación para el Desarrollo de la Investigación Estudiantil en Ciencias de la Salud (ADIECS), Lima, Peru; Universidad Nacional Mayor de San Marcos, Facultad de Medicina, Lima, Peru.
| | - Carlos Alva-Diaz
- Escuela de Medicina Humana, Facultad de Ciencias de la Salud, Universidad Científica del Sur, Lima, Peru; Grupo de Investigación "Neurociencias y Efectividad Clínica y Salud Pública", Facultad de Ciencias de la Salud, Universidad Científica del Sur, Lima, Peru.
| | - Joel Sequeiros
- Department of Neurology, University of Tennessee Health Science Center (UTHSC), Memphis, TN, USA.
| | - Carlos Abanto
- Departamento de Enfermedades Neurovasculares, Instituto Nacional de Ciencias Neurológicas, Lima, Peru.
| | - Kevin Pacheco-Barrios
- Universidad San Ignacio de Loyola, Vicerrectorado de Investigación, Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Lima, Peru; Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Cantone M, Lanza G, Puglisi V, Vinciguerra L, Mandelli J, Fisicaro F, Pennisi M, Bella R, Ciurleo R, Bramanti A. Hypertensive Crisis in Acute Cerebrovascular Diseases Presenting at the Emergency Department: A Narrative Review. Brain Sci 2021; 11:70. [PMID: 33430236 PMCID: PMC7825668 DOI: 10.3390/brainsci11010070] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/02/2021] [Accepted: 01/04/2021] [Indexed: 02/07/2023] Open
Abstract
Hypertensive crisis, defined as an increase in systolic blood pressure >179 mmHg or diastolic blood pressure >109 mmHg, typically causes end-organ damage; the brain is an elective and early target, among others. The strong relationship between arterial hypertension and cerebrovascular diseases is supported by extensive evidence, with hypertension being the main modifiable risk factor for both ischemic and hemorrhagic stroke, especially when it is uncontrolled or rapidly increasing. However, despite the large amount of data on the preventive strategies and therapeutic measures that can be adopted, the management of high BP in patients with acute cerebrovascular diseases presenting at the emergency department is still an area of debate. Overall, the outcome of stroke patients with high blood pressure values basically depends on the occurrence of hypertensive emergency or hypertensive urgency, the treatment regimen adopted, the drug dosages and their timing, and certain stroke features. In this narrative review, we provide a timely update on the current treatment, debated issues, and future directions related to hypertensive crisis in patients referred to the emergency department because of an acute cerebrovascular event. This will also focus greater attention on the management of certain stroke-related, time-dependent interventions, such as intravenous thrombolysis and mechanic thrombectomy.
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Affiliation(s)
- Mariagiovanna Cantone
- Department of Neurology, Sant’Elia Hospital, ASP Caltanissetta, Via Luigi Russo, 6, 93100 Caltanissetta, Italy;
| | - Giuseppe Lanza
- Department of Surgery and Medical-Surgical Specialties, University of Catania, Via Santa Sofia, 78, 95123 Catania, Italy
- Department of Neurology IC, Oasi Research Institute—IRCCS, Via Conte Ruggero, 73, 94018 Troina, Italy
| | - Valentina Puglisi
- Department of Neurology and Stroke Unit, ASST Cremona, Viale Concordia, 1, 26100 Cremona, Italy; (V.P.); (L.V.)
| | - Luisa Vinciguerra
- Department of Neurology and Stroke Unit, ASST Cremona, Viale Concordia, 1, 26100 Cremona, Italy; (V.P.); (L.V.)
| | - Jaime Mandelli
- Department of Neurosurgery, Sant’Elia Hospital, ASP Caltanissetta, Via Luigi Russo, 6, 93100 Caltanissetta, Italy;
| | - Francesco Fisicaro
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia, 89, 95123 Catania, Italy; (F.F.); (M.P.)
| | - Manuela Pennisi
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia, 89, 95123 Catania, Italy; (F.F.); (M.P.)
| | - Rita Bella
- Department of Medical and Surgical Sciences and Advanced Technologies, University of Catania, Via Santa Sofia, 78, 95123 Catania, Italy;
| | - Rosella Ciurleo
- IRCCS Centro Neurolesi Bonino-Pulejo, S.S. 113, Via Palermo C/da Casazza, 98123 Messina, Italy; (R.C.); (A.B.)
| | - Alessia Bramanti
- IRCCS Centro Neurolesi Bonino-Pulejo, S.S. 113, Via Palermo C/da Casazza, 98123 Messina, Italy; (R.C.); (A.B.)
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Hypertensive Crisis in Acute Cerebrovascular Diseases Presenting at the Emergency Department: A Narrative Review. Brain Sci 2021. [PMID: 33430236 DOI: 10.3390/brainsci11010070.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Hypertensive crisis, defined as an increase in systolic blood pressure >179 mmHg or diastolic blood pressure >109 mmHg, typically causes end-organ damage; the brain is an elective and early target, among others. The strong relationship between arterial hypertension and cerebrovascular diseases is supported by extensive evidence, with hypertension being the main modifiable risk factor for both ischemic and hemorrhagic stroke, especially when it is uncontrolled or rapidly increasing. However, despite the large amount of data on the preventive strategies and therapeutic measures that can be adopted, the management of high BP in patients with acute cerebrovascular diseases presenting at the emergency department is still an area of debate. Overall, the outcome of stroke patients with high blood pressure values basically depends on the occurrence of hypertensive emergency or hypertensive urgency, the treatment regimen adopted, the drug dosages and their timing, and certain stroke features. In this narrative review, we provide a timely update on the current treatment, debated issues, and future directions related to hypertensive crisis in patients referred to the emergency department because of an acute cerebrovascular event. This will also focus greater attention on the management of certain stroke-related, time-dependent interventions, such as intravenous thrombolysis and mechanic thrombectomy.
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The Unsolved Conundrum of Optimal Blood Pressure Target During Acute Haemorrhagic Stroke: A Comprehensive Analysis. High Blood Press Cardiovasc Prev 2019; 26:119-126. [PMID: 30779025 DOI: 10.1007/s40292-019-00305-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 02/05/2019] [Indexed: 12/13/2022] Open
Abstract
Intracerebral haemorrhage (ICH) is a devastating cerebrovascular disease, which accounts to 15% of all strokes. Among modifiable risk factors for ICH, hypertension is the most frequent. High blood pressure (BP) is detected in more than 75-80% of patients with ICH. Extremely elevated BP has been associated with early hematoma growth, a relatively frequent occurrence and powerful predictor of poor outcome in patients with spontaneous ICH. On the other hand, excessively low BP might cause cerebral hypoperfusion and ultimately lead to poor outcome. This review will analyse the most important trials that have tried to establish how far should BP be lowered during acute ICH. These trials have demonstrated either a small non-significant benefit (INTERACT-2, INTEnsive blood pressure Reduction in Acute Cerebral haemorrhage Trial) or no benefit (ATACH-2, Antihypertensive treatment of acute cerebral haemorrhage II study) when intensive systolic BP reduction was compared with modest or standard BP reduction. The more recent meta-analyses including studies investigating this issue yielded similar conclusions: aggressive BP control in the acute phase of ICH is not beneficial. For these reasons the 2018 European Society of Cardiology/ European Society of Hypertension Guidelines for the management of arterial hypertension, do not recommend treatment to immediately lower BP in patients with acute ICH and systolic BP < 220 mmHg. Careful lowering of SBP to less than 180 mmHg via i.v. Infusion may be considered only in patients with SBP ≥ 220 mmHg.
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Salvetti M, Paini A, Bertacchini F, Aggiusti C, Stassaldi D, Verzeri L, Saccà G, Muiesan ML. Therapeutic Approach to Hypertensive Emergencies: Hemorrhagic Stroke. High Blood Press Cardiovasc Prev 2018; 25:191-195. [DOI: 10.1007/s40292-018-0262-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 05/23/2018] [Indexed: 12/29/2022] Open
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