Page 138 - Read Online

Akinci et al. Vessel Plus 2021;5:56 https://dx.doi.org/10.20517/2574-1209.2021.20 Page 11 of 20

[61]
In the follow-up analysis of Wang et al. , effects of SBP reduction in terms of death or major disability at
90 days over three time periods (15-60 min, 1-24 h, and 2-7 days) after randomization were analyzed.
Optimal recovery was associated with the greatest reduction in SBP (≥ 20 mmHg) achieved in the first hour
and sustained for 7 days.

In another follow-up analysis, intensive BP reduction found to be beneficial on physical function at 90 days
across a wide range of initial SBP levels (< 160, 160-169, 170-179, 180-189, and ≥ 190 mmHg) and SBP level
of 130-139 mmHg provided maximum benefit . Compared with achieved SBP of 130 mmHg, adjusted
[62]
ORs for poor outcome were 1.21 at 140 mmHg, 1.42 at 150 mmHg, 1.57 at 160 mmHg, 2.19 at 170 mmHg,
and 3.04 at 180 mmHg. Death or major disability rate was slightly increased at 120 mmHg compared with
130 mmHg.

[52]
Meta-analysis of Koch et al. , INTERACT, ICH ADAPT, INTERACT-2, 2014
This meta-analysis including 3315 acute ICH patients, indicated that intensive BP lowering (target SBP <
150 mmHg or MAP < 110 mmHg) was safe . Mortality rates were similar between intensive and guideline
[63]
BP treatment groups. Intensive BP reduction lowered 3-month death and dependency (mRS grades 3-6)
and absolute hematoma growth at 24 h.

ENOS, 2015
In the Efficacy of Nitric Oxide in Stroke Trial (ENOS), 4011 stroke patients (ischemic or hemorrhagic,) with
SBP 140-220 mmHg, within 48 h of symptom onset were randomized to transdermal glyceryl trinitrate
[64]
(GTN) treatment (n = 1993) or no GTN (n = 2002) for one week . The average time of randomization was
26 h. Transdermal GTN lowered BP and was found to be safe and potentially beneficial if started within 6 h
of stroke onset. However, the distribution of mRS between two groups did not differ. Subgroup analysis of
629 ICH patients with a mean baseline BP of 172.1/93.4 mmHg showed no difference in the mRS and in the
rates of SAEs between GTN (n = 310) and no GTN (n = 319) groups . When adjusted for baseline value,
[65]
GTN treatment caused a smaller hematoma volume (mean difference, -4.3 cm ; P = 0.06) in 181 patients
3
whose brain imaging repeated one week later. Starting GTN treatment within 6 h was associated with better
outcomes (mRS score, early impairment, late dependency, late cognition, mood, life quality, disability, and
death)

[66]
Gong et al. , 2015
Gong et al. investigated the effect of BP control in ultra-early ICH. One hundred and twenty ICH patients
[66]
with SBP > 160 mmHg, within 4 h of symptom onset were divided into strengthened antihypertensive
(target SBP 130-140 mmHg; n = 60) and standard antihypertensive (target SBP 160-180 mmHg; n = 60)
group. IV nitroglycerin was used. Mean time of treatment initiation after symptom onset in the
strengthened and standard treatment group was 2.24 ± 1.23 h and 2.13 ± 1.05 h, respectively. In this study,
where treatment was started much earlier compared to others, strengthened treatment significantly lowered
hematoma volume and hematoma enlargement after 24 h and National Institutes of Health Stroke Scale
(NIHSS) score on day 14. Additionally, cerebral edema amount and serum matrix metalloproteinase-9 level
(related to the prognosis of brain hemorrhage) after 5 days and 14 days were significantly lower in the
experimental group .
[67]
ATACH-2, 2016
The ATACH-2 trial investigated the effectiveness of rapid SBP lowering in ICH patients with SBP >
180 mmHg (determined on the basis that a greater therapeutic benefit would be shown by excluding
patients who did not require IV antihypertensive treatment) in an earlier time window (within 4.5 h from
symptom onset). Patients randomized to intensive treatment (target SBP 110-139 mmHg; n = 500) or