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Published on: July 3, 2014
Triple Antihypertensive Medication Prediction Score After Intracerebral Hemorrhage (the TRICH Score)
Ching Hei So1, Charming Yeung1, Ryan Wui-Hang Ho1
1Division of Neurology, Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.
Insights
A new TRICH score helps identify patients needing multiple blood pressure medications after intracerebral hemorrhage (ICH). This tool aids in personalized treatment to prevent recurrent strokes and improve long-term outcomes.
Area of Science:
- Neurology
- Cardiology
- Clinical Prediction Models
Background:
- Intracerebral hemorrhage (ICH) survivors often face poor long-term blood pressure (BP) control due to undertreatment, increasing risks of recurrence and stroke.
- Prompt BP target achievement is crucial, but upfront triple antihypertensive medication may not suit all patients, especially those with cerebral amyloid angiopathy (CAA).
- Overtreatment and excessive BP lowering can lead to adverse effects and mortality, necessitating individualized treatment strategies.
Purpose of the Study:
- To develop and validate a clinical score (TRICH) to predict the need for three or more antihypertensive medications at 3 months post-ICH.
- To facilitate individualized treatment decisions for hypertension management after ICH.
Main Methods:
- The TRICH score was developed using data from a prospective ICH registry (2011-2022) and validated across three hospitals (2020-2022).
- Multivariate logistic regression identified predictors for needing ≥3 antihypertensives at 3 months in spontaneous ICH survivors.
- The score was constructed using β-coefficients from the regression model.
Main Results:
- The 9-point TRICH score, incorporating age, sex, ischemic heart disease, eGFR, and admission systolic BP, demonstrated good predictive ability (c-statistic 0.79 in development, 0.76 in validation).
- A dichotomized score (≥3 points) showed 73% sensitivity and 76% specificity for predicting the need for ≥3 antihypertensives.
- The score performed better in patients with untreated/uncontrolled pre-ICH hypertension compared to controlled patients.
Conclusions:
- The TRICH score effectively identifies ICH patients requiring multiple antihypertensive medications, aiding in treatment personalization.
- This score may guide upfront triple antihypertensive prescription strategies post-ICH.
- Further research is recommended, particularly in diverse populations, to refine its application.
Background And Objectives:
Poor long-term blood pressure (BP) control due to undertreatment of hypertension is not uncommon after intracerebral hemorrhage (ICH). It heightens the risk of ICH recurrence and subsequent stroke, which is the highest within the first year. Promptly achieving BP targets would significantly reduce these risks. To accomplish this, upfront triple antihypertensive medications could be prescribed soon after ICH because many ICH survivors require ≥3 antihypertensives. However, not all would suit this approach, particularly those with cerebral amyloid angiopathy (CAA), where elevated admission BP may be due to acute hypertensive response rather than underlying hypertension. In addition, overtreatment and excessive BP lowering would cause more side effects and have been associated with increased mortality in older patients. Hence, to facilitate individualized treatment, we aimed to develop a score (TRICH) to predict the need for ≥3 antihypertensives at 3 months after ICH.
Methods:
We developed the score using data from the University of Hong Kong prospective ICH registry (2011-2022) and validated it in 3 hospitals (2020-2022) locally. Consecutive patients with spontaneous ICH who survived >90 days and had follow-up BP 3 months after ICH were included. Predictors for needing ≥3 antihypertensive medications at 3 months were identified using multivariate logistic regression, and the score was created using the β-coefficients.
Results:
The TRICH score was developed from 462 patients (mean age 66.6 ± 14.3 years, 60% male) and validated in 203 patients (mean age 66.3 ± 14.6 years, 62% male). The 9-point score (age younger than 60 years = 1, male = 1, ischemic heart disease = 1, admission estimated glomerular filtration rate <60 mL/min/1.73 m2 = 2, admission systolic BP 190-230 mm Hg = 2 while >230 mm Hg = 4) has a c-statistic (95% CI) of 0.79 (0.75-0.83) in the development cohort and 0.76 (0.69-0.82) in validation. A dichotomized score (≥3 points) predicted the need for ≥3 antihypertensives with 0.73 (95% CI 0.67-0.80) sensitivity and 0.76 (95% CI 0.70-0.81) specificity. The score performed better in patients with untreated/uncontrolled hypertension before ICH than in controlled patients (c-statistic [95% CI] 0.81 [0.77-0.86] vs 0.74 [0.69-0.80], p = 0.037) but showed no difference between patients with CAA and non-CAA patients.
Discussion:
The TRICH score identifies patients with ICH who need ≥3 antihypertensive medications 3 months after ICH with good discrimination ability. It may guide upfront triple antihypertensive prescription, but further research is warranted, particularly in non-Han Chinese populations.
