Adnan I Qureshi1, Yuko Y Palesch1, William G Barsan1, Daniel F Hanley1, Chung Y Hsu1, Renee L Martin1, Claudia S Moy1, Robert Silbergleit1, Thorsten Steiner1, Jose I Suarez1, Kazunori Toyoda1, Yongjun Wang1, Haruko Yamamoto1, Byung-Woo Yoon1. 1. From the Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis (A.I.Q.); the Department of Public Health Sciences, Medical University of South Carolina, Charleston (Y.Y.P., R.L.M.); the Department of Emergency Medicine, University of Michigan, Ann Arbor (W.G.B., R.S.); the Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore (D.F.H.), and the Neurological Institute, National Institute of Neurological Disorders and Stroke, Bethesda (C.S.M.) - both in Maryland; China Medical University, Taichung, Taiwan (C.Y.H.); the Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, and the Department of Neurology, Heidelberg University Hospital, Heidelberg - both in Germany (T.S.); the Department of Neurology, Baylor College of Medicine, Houston (J.I.S.); the Departments of Cerebrovascular Medicine (K.T.) and Data Sciences (H.Y.), National Cerebral and Cardiovascular Center, Suita, Japan; Beijing Tiantan Hospital, Beijing (Y.W.); and the Department of Neurology, Seoul National University Hospital, Seoul, South Korea (B.-W.Y.).
Abstract
BACKGROUND: Limited data are available to guide the choice of a target for the systolic blood-pressure level when treating acute hypertensive response in patients with intracerebral hemorrhage. METHODS: We randomly assigned eligible participants with intracerebral hemorrhage (volume, <60 cm(3)) and a Glasgow Coma Scale (GCS) score of 5 or more (on a scale from 3 to 15, with lower scores indicating worse condition) to a systolic blood-pressure target of 110 to 139 mmHg (intensive treatment) or a target of 140 to 179 mm Hg (standard treatment) in order to test the superiority of intensive reduction of systolic blood pressure to standard reduction; intravenous nicardipine to lower blood pressure was administered within 4.5 hours after symptom onset. The primary outcome was death or disability (modified Rankin scale score of 4 to 6, on a scale ranging from 0 [no symptoms] to 6 [death]) at 3 months after randomization, as ascertained by an investigator who was unaware of the treatment assignments. RESULTS: Among 1000 participants with a mean (±SD) systolic blood pressure of 200.6±27.0 mm Hg at baseline, 500 were assigned to intensive treatment and 500 to standard treatment. The mean age of the patients was 61.9 years, and 56.2% were Asian. Enrollment was stopped because of futility after a prespecified interim analysis. The primary outcome of death or disability was observed in 38.7% of the participants (186 of 481) in the intensive-treatment group and in 37.7% (181 of 480) in the standard-treatment group (relative risk, 1.04; 95% confidence interval, 0.85 to 1.27; analysis was adjusted for age, initial GCS score, and presence or absence of intraventricular hemorrhage). Serious adverse events occurring within 72 hours after randomization that were considered by the site investigator to be related to treatment were reported in 1.6% of the patients in the intensive-treatment group and in 1.2% of those in the standard-treatment group. The rate of renal adverse events within 7 days after randomization was significantly higher in the intensive-treatment group than in the standard-treatment group (9.0% vs. 4.0%, P=0.002). CONCLUSIONS: The treatment of participants with intracerebral hemorrhage to achieve a target systolic blood pressure of 110 to 139 mm Hg did not result in a lower rate of death or disability than standard reduction to a target of 140 to 179 mm Hg. (Funded by the National Institute of Neurological Disorders and Stroke and the National Cerebral and Cardiovascular Center; ATACH-2 ClinicalTrials.gov number, NCT01176565 .).
RCT Entities:
BACKGROUND: Limited data are available to guide the choice of a target for the systolic blood-pressure level when treating acute hypertensive response in patients with intracerebral hemorrhage. METHODS: We randomly assigned eligible participants with intracerebral hemorrhage (volume, <60 cm(3)) and a Glasgow Coma Scale (GCS) score of 5 or more (on a scale from 3 to 15, with lower scores indicating worse condition) to a systolic blood-pressure target of 110 to 139 mm Hg (intensive treatment) or a target of 140 to 179 mm Hg (standard treatment) in order to test the superiority of intensive reduction of systolic blood pressure to standard reduction; intravenous nicardipine to lower blood pressure was administered within 4.5 hours after symptom onset. The primary outcome was death or disability (modified Rankin scale score of 4 to 6, on a scale ranging from 0 [no symptoms] to 6 [death]) at 3 months after randomization, as ascertained by an investigator who was unaware of the treatment assignments. RESULTS: Among 1000 participants with a mean (±SD) systolic blood pressure of 200.6±27.0 mm Hg at baseline, 500 were assigned to intensive treatment and 500 to standard treatment. The mean age of the patients was 61.9 years, and 56.2% were Asian. Enrollment was stopped because of futility after a prespecified interim analysis. The primary outcome of death or disability was observed in 38.7% of the participants (186 of 481) in the intensive-treatment group and in 37.7% (181 of 480) in the standard-treatment group (relative risk, 1.04; 95% confidence interval, 0.85 to 1.27; analysis was adjusted for age, initial GCS score, and presence or absence of intraventricular hemorrhage). Serious adverse events occurring within 72 hours after randomization that were considered by the site investigator to be related to treatment were reported in 1.6% of the patients in the intensive-treatment group and in 1.2% of those in the standard-treatment group. The rate of renal adverse events within 7 days after randomization was significantly higher in the intensive-treatment group than in the standard-treatment group (9.0% vs. 4.0%, P=0.002). CONCLUSIONS: The treatment of participants with intracerebral hemorrhage to achieve a target systolic blood pressure of 110 to 139 mm Hg did not result in a lower rate of death or disability than standard reduction to a target of 140 to 179 mm Hg. (Funded by the National Institute of Neurological Disorders and Stroke and the National Cerebral and Cardiovascular Center; ATACH-2 ClinicalTrials.gov number, NCT01176565 .).
Authors: Adnan I Qureshi; Yuko Y Palesch; Reneé Martin; Jill Novitzke; Salvador Cruz-Flores; As'ad Ehtisham; Mustapha A Ezzeddine; Joshua N Goldstein; Haitham M Hussein; M Fareed K Suri; Nauman Tariq Journal: Arch Neurol Date: 2010-05
Authors: Thorsten Steiner; Markku Kaste; Markku Katse; Michael Forsting; David Mendelow; Hubert Kwiecinski; Istvan Szikora; Seppo Juvela; Andrzej Marchel; René Chapot; Christophe Cognard; Andreas Unterberg; Werner Hacke Journal: Cerebrovasc Dis Date: 2006-07-28 Impact factor: 2.762
Authors: Joseph P Broderick; Michael N Diringer; Michael D Hill; Nikolai C Brun; Stephan A Mayer; Thorsten Steiner; Brett E Skolnick; Stephen M Davis Journal: Stroke Date: 2007-02-08 Impact factor: 7.914
Authors: Craig S Anderson; Yining Huang; Hisatomi Arima; Emma Heeley; Christian Skulina; Mark W Parsons; Bin Peng; Qiang Li; Steve Su; Qing Ling Tao; Yue Chun Li; Jian Dong Jiang; Li Wen Tai; Jin Li Zhang; En Xu; Yan Cheng; Lewis B Morgenstern; John Chalmers; Ji Guang Wang Journal: Stroke Date: 2009-12-31 Impact factor: 7.914
Authors: Andrea Morotti; Javier M Romero; Michael J Jessel; Andrew M Hernandez; Anastasia Vashkevich; Kristin Schwab; Joseph D Burns; Qaisar A Shah; Thomas A Bergman; M Fareed K Suri; Mustapha Ezzeddine; Jawad F Kirmani; Sachin Agarwal; Angela Hays Shapshak; Steven R Messe; Chitra Venkatasubramanian; Katherine Palmieri; Christopher Lewandowski; Tiffany R Chang; Ira Chang; David Z Rose; Wade Smith; Chung Y Hsu; Chun-Lin Liu; Li-Ming Lien; Chen-Yu Hsiao; Toru Iwama; Mohammad Rauf Afzal; Christy Cassarly; Steven M Greenberg; Renee' Hebert Martin; Adnan I Qureshi; Jonathan Rosand; John M Boone; Joshua N Goldstein Journal: Neuroradiology Date: 2017-07-20 Impact factor: 2.804
Authors: Nikita Leiter; Melissa Motta; Robert M Reed; Temitope Adeyeye; Debra L Wiegand; Nirav G Shah; Avelino C Verceles; Giora Netzer Journal: Crit Care Med Date: 2018-02 Impact factor: 7.598
Authors: David Roh; Chung-Huan Sun; J Michael Schmidt; Edip Gurol; Santosh Murthy; Soojin Park; Sachin Agarwal; E Sander Connolly; Jan Claassen Journal: Neurocrit Care Date: 2018-08 Impact factor: 3.210
Authors: Andrea Morotti; Gregoire Boulouis; Andreas Charidimou; Kristin Schwab; Christina Kourkoulis; Christopher D Anderson; M Edip Gurol; Anand Viswanathan; Javier M Romero; Steven M Greenberg; Jonathan Rosand; Joshua N Goldstein Journal: Stroke Date: 2018-09 Impact factor: 7.914