JNNP: Early blood pressure reduction after acute cerebral hemorrhage, a systematic review and meta-analysis of individual patient data

Increased blood pressure (BP) after acute spontaneous intracerebral hemorrhage (ICH) is associated with adverse clinical outcomes
.

Studies have shown that achieving and maintaining a systolic blood pressure level as low as 120–130 mmHg within the first 24 hours can reduce hematoma enlargement and improve the prognosis of functional nodes

However, there are still uncertainties regarding the impact of different antihypertensive interventions on clinical outcomes, as well as the most likely mechanism of action (hematoma growth)

The IPD meta-analysis is considered the gold standard for summarizing evidence from randomized controlled trials ( RCT)
.

The purpose of the International Acute Stroke Blood Pressure Collaboration (BASC) is to conduct a detailed analysis of the comprehensive IPD of RCTs managed by BP after acute stroke

Randomized controlled trial ( showing the results of antihypertensive intervention after acute cerebral hemorrhage on the prognosis, focusing on determining whether there is an effect that changes due to patient characteristics, antihypertensive intervention strategies, time or drugs

This article is a randomized controlled trial evaluating the effects of different antihypertensive strategies in the acute phase of stroke (within 7 days)
.

Qualified studies are identified in the Cochrane Central Controlled Trials Register, EMBASE and MEDLINE databases from inception to June 23, 2020.

This article is a randomized controlled trial evaluating the effects of different antihypertensive strategies in the acute phase of stroke (within 7 days)

Research flow chart
.

Modified Rankin Scale; NIHSS, National Institutes of Health Stroke Scale

Two authors screened the title and abstract, and evaluated the eligibility of the full-text article based on the inclusion criteria
.

We sent our proposal and invitation letter to qualified research researchers, inviting them to join BASC and share intellectual property rights

Two authors screened the title and abstract, and evaluated the eligibility of the full-text article based on the inclusion criteria

Two minimal data sets for preliminary analysis were developed in Sydney and Nottingham; adjustments for covariates included trials (treatment allocation, time from symptom onset to randomization), demographics (age and gender), and baseline clinical characteristics

Effects of antihypertensive intervention in the active/intensified group and placebo/guideline group on the main outcomes of the subgroups after acute cerebral hemorrhage

Use the intention-to-treat data set of each trial for preliminary analysis, using the one-stage method of IPD meta-analysis
.

The one-stage approach provides additional statistical power and flexibility by merging all IPDs into a single meta-analysis, and allows for subgroup analysis based on individual characteristics of interest
.
The patients who did not have the smallest data set for covariate adjustment were excluded
.
Descriptive statistics are described as the mean (SD) or median (IQR) of continuous data, or the frequency (percentage) of categorical data, and are compared using Kruskal-Wallis or χ2 test
.
Use a generalized linear mixed model with pre-specified covariates (age, gender, NIHSS score, time from symptom onset to randomization)
.
Test patient characteristics and the impact of strategies, timing, and drugs used in antihypertensive interventions on the results, and use interaction terms in the model for subgroup analysis
.

Of the 7094 studies identified, 50 trials (involving 11494 patients) were eligible, and 16 (32.
0%) shared data on 6221 (54.
1%) patients (mean age 64.
2, 2266 [36.
4%] women) , The median time from symptom onset to randomization was 3.
8 hours (IQR 2.
6–5.
3)
.
Compared with placebo/guideline treatment, active/intensive antihypertensive interventions had no effect on the main outcome (adverse changes in adjusted or modified Rankin scale scores: 0.
97, 95% confidence interval 0.
88 to 1.
06; p=0.
50), However, there is significant heterogeneity between treatment methods (pinteraction=0.
031) and drugs (pinteraction<0.
0001)
.
Active/intensified antihypertensive intervention significantly reduced the growth of hematoma
.

Effect of antihypertensive intervention in the active/intensified group and placebo/guideline group on the growth of absolute hematoma after acute intracerebral hemorrhage (ICH)

The results show that moderate blood pressure reduction does not improve functional outcomes for 3-6 months
.
However, lower blood pressure can reduce the risk of hematoma growth.
Depending on the patient’s age, gender, and baseline hematoma volume, this is a factor closely related to poor prognosis
.
The most effective strategy for lowering blood pressure after acute cerebral hemorrhage is still uncertain
.
The study included patients who received a wide range of interventions and compared them through these interventions: In a pre-specified subgroup analysis, according to the strategy used to lower blood pressure, significant heterogeneity in the treatment effect was found
.
Compared with patients treated with fixed-active drugs, patients who received titrated to intensive antihypertensive intervention had a greater reduction in systolic blood pressure and better functional results
.
These findings are supported by previous observational analysis of the aggregated data of two randomized controlled trials (n=3829), which showed that targeted and sustained systolic blood pressure reduction (down to 120-130 mmHg in the first 24 hours) was Safe and related to better functional results
.

The results show that moderate blood pressure reduction does not improve functional outcomes for 3-6 months
.
However, lower blood pressure can reduce the risk of hematoma growth.
Depending on the patient’s age, gender, and baseline hematoma volume, this is a factor closely related to poor prognosis
.
The results show that moderate blood pressure reduction does not improve functional outcomes for 3-6 months
.
However, lower blood pressure can reduce the risk of hematoma growth.
Depending on the patient’s age, gender, and baseline hematoma volume, this is a factor closely related to poor prognosis
.
This shows that targeted and sustained systolic blood pressure reduction (down to 120-130 mmHg in the first 24 hours) is safe and is associated with better functional outcomes
.
This shows that targeted and sustained systolic blood pressure reduction (down to 120-130 mmHg in the first 24 hours) is safe and is associated with better functional outcomes
.

In general, despite the reduction in bleeding, extensive interventions to lower blood pressure within 7 days after the onset of cerebral hemorrhage have no overall benefit for functional recovery
.
The treatment effect seems to vary depending on the treatment method and medication
.

Moullaali  TJ ,  Wang  X ,  Sandset  EC Moullaali  TJMoullaali Wang  XWang Sandset  ECSandset, et alEarly lowering of blood pressure after acute intracerebral haemorrhage: a systematic review and meta-analysis of individual patient dataJournal of Neurology, Neurosurgery & Psychiatry  Online First:  03 November 2021.
 Published Online First: doi:  10.
1136/jnnp-2021-327195doi:Leave a message here