What is the target blood pressure (BP) in a patient with a hypertensive intracranial hemorrhage (hypertensive bleed)?

From the Guidelines

For patients with hypertensive intracranial hemorrhage, the target blood pressure should be a systolic target of 140-160 mmHg to prevent hematoma expansion and improve functional outcome. This recommendation is based on the most recent and highest quality study, the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. The guidelines suggest that immediate blood pressure lowering within 6 hours of symptom onset should be considered to achieve this target. It is also important to note that in patients with intracerebral hemorrhage presenting with systolic BP ≥220 mmHg, acute reduction in systolic BP >70 mmHg from initial levels within 1 hour of commencing treatment is not recommended 1.

Some key points to consider in managing blood pressure in patients with hypertensive intracranial hemorrhage include:

• Achieving the target blood pressure within the first few hours after symptom onset
• Maintaining the target blood pressure for at least the first 24-72 hours
• Using preferred medications for acute BP lowering, such as intravenous nicardipine, labetalol, or clevidipine
• Continuous BP monitoring, preferably with an arterial line for precise measurements
• Adjusting BP targets according to individual patient needs, such as those with elevated intracranial pressure or at risk for cerebral ischemia.

The rationale behind this target is that elevated BP can worsen bleeding and increase intracranial pressure, while excessively low BP might compromise cerebral perfusion 1. Previous studies, such as the INTERACT1 and ATACH trials, have shown that intensive BP lowering is clinically feasible and potentially safe, but the optimal BP target and duration of therapy remain unclear 1. However, the 2024 ESC guidelines provide the most up-to-date and evidence-based recommendation for managing blood pressure in patients with hypertensive intracranial hemorrhage.

From the Research

Target Blood Pressure in Hypertensive Bleed

• The target blood pressure (BP) in a patient with a hypertensive intracranial hemorrhage (hypertensive bleed) is a critical aspect of management, with the goal of reducing the risk of hematoma expansion and rebleeding 2.
• Studies have shown that lowering systolic blood pressure (SBP) to 160 mmHg or less using intravenous nicardipine is well tolerated and feasible in acute intracerebral hemorrhage patients 3.
• The American Heart Association recommends targeting a systolic blood pressure of less than 140 mmHg in most hypertensive patients, but this may not be appropriate for all patients with hypertensive bleed 4.
• In patients with reduced ejection fractions presenting with acute heart failure with hypertension, a median physician-specified SBP goal of 160 mmHg has been used, with nicardipine found to be safe and effective in achieving this goal 5.
• The choice of antihypertensive agent, such as nicardipine or labetalol, may depend on the individual patient's characteristics and the presence of end-organ damage 6.

Blood Pressure Management

• Intravenous nicardipine has been shown to be effective in reducing SBP in patients with hypertensive bleed, with a median time to goal SBP of 18 minutes 5.
• The use of nicardipine in patients with reduced ejection fractions has been found to be safe and effective, with a low incidence of adverse events such as hypotension and bradycardia 5.
• The Stroke Acute Management with Urgent Risk-factor Assessment and Improvement-Intracerebral Hemorrhage study found that SBP lowering to 160 mmHg or less using nicardipine was well tolerated and feasible in acute intracerebral hemorrhage patients, with a low incidence of neurological deterioration and serious adverse effects 3.