Poor BP Control Tied to Recurrent Hemorrhagic Stroke

Survivors of intracerebral hemorrhage (ICH) who had subsequent inadequate blood pressure (BP) control were at higher risk of stroke recurrence, according to a new study.

Researchers at Massachusetts General Hospital (MGH; Boston, MA, USA) and the Broad Institute (Cambridge, MA, USA) conducted an observational cohort study involving 1,145 patients who survived at least 90 days following ICH. BP measurements were obtained at 3, 6, 9, and 12 months, and every 6 months thereafter for up to three years. Exposure was characterized by BP measurements; classification as adequate or inadequate BP control; and JNC-7 stage of hypertension. The main outcomes and measures were recurrent ICH and its location within the brain (lobar versus nonlobar).

The results showed 102 recurrent ICH events among 505 survivors of lobar ICH, and 44 recurrent ICH events among 640 survivors of nonlobar ICH. The event rate for lobar ICH was 84 per 1,000 person-years among patients with inadequate BP control, compared with 49 per 1,000 person-years among patients with adequate BP control. For nonlobar ICH, the event rate was 52 per 1,000 person-years with inadequate BP control compared with 27 per 1,000 person-years for patients with adequate BP control.

The researchers found that BP control was achieved in less than 50% of ICH survivors, and only 60% of patients ever achieved recommended systolic or diastolic BP goals. Inadequate overall BP and systolic BP control during follow-up was associated with increased risk of both lobar and nonlobar ICH recurrence. Diastolic BP, on the other hand, although associated with increased risk of nonlobar ICH recurrence, was not associated with lobar ICH recurrence. The study was published on September 1, 2015, in the Journal of the American Medical Association (JAMA).

“The association between elevated BP and ICH recurrence appeared to become stronger with worsening severity of hypertension as defined under JNC-7 severity stages,” concluded senior author Jonathan Rosand, MD, MSc, and colleagues. "These results confirm that ICH survivors are at high risk for recurrence, and support the hypothesis that aggressive blood pressure control may reduce this risk substantially.”

ICH is the second most common cause of stroke, accounting for 10% of hospital admissions. As with other types of hemorrhages within the skull, they are serious medical emergency because they can increase intracranial pressure, which if left untreated can lead to coma and death. High BP raises the risks of spontaneous ICH by two to six times. Lobar ICH generally carries a poorer prognosis than nonlobar ICH, as the bleeding occurs in the cerebral tissue.

The 2014 JNC 8 evidence-based guideline included some notable differences compared with the previous JNC 7 guideline, increasing the systolic BP treatment goal from less than 140/90 mmHg to less than 150/90 mmHg. The less restrictive BP targets are recommended for adults 60 years of age or older and for those with diabetes and chronic kidney disease (CKD).

Related Links:
Massachusetts General Hospital
Broad Institute