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

Tom J. Moullaali, Xia Wang, Else Charlotte Sandset, Lisa J. Woodhouse, Zhe Kang Law, Hisatomi Arima, Kenneth S. Butcher, John Chalmers, Candice Delcourt, Leon Edwards, Salil Gupta, Wen Jiang, Sebastian Koch, John Potter, Adnan I. Qureshi, Thompson G. Robinson, Rustam Al-Shahi Salman, Jeffrey L. Saver, Nikola Sprigg, Joanna M. WardlawCraig S. Anderson, Philip M. Bath, On behalf of the Blood Pressure in Acute Stroke (BASC) Investigators

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Abstract

Objective: To summarise evidence of the effects of blood pressure (BP)-lowering interventions after acute spontaneous intracerebral haemorrhage (ICH). Methods: A pre-specified 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 vs. placebo or intensive vs. 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 (>6ml) and proportional (>33%) haematoma growth at 24 hours. Meta-analysis used a one-stage approach, adjusted using generalised linear mixed models with pre-specified 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 6,221 (54.1%) patients (mean age 64.2 [SD 12.9], 2,266 [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 to placebo/guideline treatment (adjusted OR for unfavourable shift in modified Rankin scale scores: 0.97, 95% confidence interval 0.88 to 1.06; p=0.50), but there was significant heterogeneity by strategy (pinteraction=0.031) and agent (pinteraction<0.0001). Active/intensive BP-lowering interventions clearly reduced absolute and relative 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.
Original languageEnglish
JournalJournal of Neurology, Neurosurgery and Psychiatry
Early online date3 Nov 2021
DOIs
Publication statusE-pub ahead of print - 3 Nov 2021

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