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Updated: Aug 10, 2025
Minimally Invasive Endoscopic Intracerebral Hemorrhage Evacuation
Published on: October 15, 2021
Adherence to Established Blood Pressure Targets and Associated Complications in Patients Presenting with Acute
Nicole A Leshko1, Raymond F Lamore2, Megan K Zielke2
1Department of Pharmacy, Northwestern Memorial Hospital, 251 E. Huron St., Chicago, IL, 60611, USA. Nicole.Leshko@nm.org.
Insights
Intensive systolic blood pressure reduction in acute intracerebral hemorrhage (ICH) patients increases risks for brain and kidney injury. A more modest SBP lowering may reduce adverse events and improve outcomes.
Area of Science:
- Neurology
- Cardiology
- Nephrology
Background:
- Conflicting evidence exists regarding optimal systolic blood pressure (SBP) control in acute intracerebral hemorrhage (ICH) patients.
- Current guidelines recommend targeting SBP of 140 mm Hg (range 130-150 mm Hg), while prior practice aimed for <160 mm Hg.
- This study investigated whether prior less stringent SBP targets predisposed patients to hypotension and adverse events.
Purpose of the Study:
- To evaluate the frequency of time spent within the SBP range of 140-160 mm Hg in the first 48 hours post-ICH admission.
- To assess secondary outcomes including hypotension, new brain or renal adverse events, and functional outcomes (modified Rankin Scale).
Main Methods:
- Retrospective, multicenter cohort study of adult ICH patients admitted between June 2019 and June 2021.
- Analysis of SBP variability (time above, within, and below target ranges) in the initial 48 hours.
- Evaluation of hypotension, organ injury, and functional outcomes.
Main Results:
- Patients spent only 34% of the first 48 hours within the 140-160 mm Hg SBP range, with 54% below 140 mm Hg.
- Hypotension (<140 mm Hg SBP) was linked to renal adverse events (OR 3.36).
- A relative SBP reduction >20% was associated with renal events (OR 8.99), brain ischemia (OR 22.5), and poor functional outcome (OR 11.79).
Conclusions:
- Over 50% of ICH patients experienced SBP <140 mm Hg in the first 48 hours, indicating frequent hypotension.
- Intensive SBP reduction and hypotension are independent predictors of secondary organ injury (renal and brain).
- A more modest SBP lowering strategy, aligning with recent guidelines, may mitigate risks and improve outcomes in ICH patients.
Background:
Conflicting evidence exists surrounding systolic blood pressure (SBP) control in patients with acute intracerebral hemorrhage (ICH). The 2022 American Heart Association and American Stroke Association guidelines recommend targeting a SBP of 140 mm Hg while maintaining the range of 130-150 mm Hg. The current practice at our health system is to titrate antihypertensives to a SBP goal of < 160 mm Hg, which aligns with previous recommendations. We hypothesized that the prior lack of guidance to a specific SBP target range predisposed patients to hypotension leading to an increased risk of brain and renal adverse events.
Methods:
This retrospective, multicenter, single health system cohort study included adults admitted to the neurointensive care unit or intermediate unit with acute ICH from June 2019 to June 2021. The primary objective evaluated the frequency of time within SBP range (140-160 mm Hg) in the first 48 h. Secondary and safety end points included the frequency of time above and below the established SBP range, episodes of hypotension (defined as a decrease in SBP < 140 mm Hg prompting discontinuation in antihypertensive[s] or the initiation of vasopressor[s]), the incidence of new brain or renal adverse events within 7 days, and modified Rankin Scale at discharge.
Results:
A total of 80 patients (59% men; median age 62 years) were included. The majority of ICHs in this cohort were intraparenchymal (70%). Nearly one third were attributed to systemic hypertension (31%). During the first 48 h of admission, the frequency of time spent above, within, and below the target SBP range were 6 h (12%), 16 h (34%), and 26 h (54%), respectively. Hypotension was associated with renal adverse events (odds ratio [OR] 3.36, 95% confidence interval [CI] 1.10-11.44, p = 0.023). A relative SBP reduction > 20% in the first 48 h was associated with renal adverse events (OR 8.99, 95% CI 2.57-35.25, p < 0.001), brain ischemia (OR 22.5, 95% CI 1.92-300.11, p = 0.005), and an increased odd of a modified Rankin Scale of 4-6 at discharge (OR 11.79, 95% CI 2.79-57.02, p < 0.001).
Conclusions:
In individuals with nontraumatic/nonaneurysmal ICH, SBP measurements were observed to be < 140 mm Hg for > 50% of the initial 48 h following admission. Hypotension and relative SBP reduction > 20% were also independent predictors of renal adverse events. SBP reduction > 20% was also an independent predictor of brain ischemia. These data indicate that intensive SBP reduction following ICH predispose patients to secondary organ injury that may impact long-term outcomes. Our data suggest that a more modest lowering of the SBP within 48 h, as recommended in the most recent guidelines, may minimize the risk of further adverse events.
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