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Aggressive BP lowering, platelet transfusion not beneficial in managing intracranial hemorrhage
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ORLANDO, Fla. – Lowering BP in patients presenting with intracranial hemorrhage to lower than 140 mm Hg has not been shown to be beneficial, and may carry additional risk, according to a presentation here at Hospital Medicine 2018.
The INTERACT-II and ATACH-II trials both reviewed the impact on patient outcomes from BP lowering, with INTERACT-II targeting systolic BP of 140 mm Hg and ATACH-II targeting 110 to 139 mm Hg. INTERACT-II showed a small improvement in the number of patients achieving a cognitive score on the mRS 3 among patients with a BP of 140 mm Hg or lower (52% vs 55.6%).
“It showed that no matter who you were — the time you presented, your age, etc. — it seemed that intensive treatment, that means getting patients down to about 140 as opposed to the mid-150s, was beneficial,” according to Aaron Lord, MD, assistant professor of neurology and neurosurgery and chief of the division of neurocritical care at New York University Langone Health.
However, the ATACH-II was “a completely negative trial,” with some patients whose BP was reduced to lower than 130 mm Hg having worse outcomes, though this finding was not statistically significant, he said. These patients normally have higher BPs, so lowering to the 110 to 120 mm Hg range may induce ischemia
“In the neurological community, the takeaway was that you want to remain as close to 140 as possible,” he added. “At our hospital, we use a range of 130 to 150.”
For patients with large intracranial hemorrhages, clinicians should be careful to avoid lowering pressure too much because those patients may have high intracranial pressure and you might decrease their cerebral perfusion pressure, Lord said.
Another frequent debate in neurology is whether to reverse patients taking aspirin, clopidogrel or other antiplatelet agents with platelets on presentation, Lord said. The PATCH Trial compared patients receiving COX inhibitors as monotherapy and in combination with dipyridamole, ADP inhibitors as monotherapy and in combination with COX inhibitors.
“The standard group did much better than the transfusion group,” Lord said. “It looks like transfusion of platelets is harmful, and if not, it’s at least not beneficial.”
Lord said that his hospital has stopped reversing patients on antiplatelet therapy, but also noted that the trial did not enroll enough patients on dual antiplatelet therapy to make a determination in those cases.
Another important trial was the INCH trial, which compared prothrombin complex concentrate (PCC) to fresh frozen plasma for treatment of intracranial bleeding related to vitamin K antagonists. The trial was stopped early because of the clear survival advantage shown by PCC, Lord said. – by Chris Rosenberg
Reference:
Lord A. Neurologic Emergencies. Presented at: Hospital Medicine 2018; April 9-11; Orlando, Fla.
Disclosure: Healio Internal Medicine was unable to confirm Lord’s disclosures.