What is the target blood pressure (BP) for patients with intracerebral hemorrhage (ICH)?

Target Blood Pressure in Acute Intracerebral Hemorrhage

For patients with acute intracerebral hemorrhage presenting with systolic blood pressure (SBP) between 150-220 mm Hg, target an SBP <140 mm Hg, initiated within 6 hours of symptom onset and maintained for at least 7 days. 1

Evidence-Based BP Targets by Clinical Scenario

SBP 150-220 mm Hg (Most Common Presentation)

• Target SBP <140 mm Hg using continuous intravenous antihypertensive therapy 1
• This target is safe (Class I, Level A evidence) and can be effective for improving functional outcome (Class IIa, Level B evidence) 1
• The INTERACT2 trial (2839 patients) demonstrated better functional recovery on ordinal analysis of modified Rankin Scale scores (OR 0.87,95% CI 0.77-1.00, P=0.04) and improved quality of life with intensive BP lowering compared to standard treatment (SBP <180 mm Hg) 1
• Achieve target within 1 hour of treatment initiation when possible 1

SBP >220 mm Hg (Severe Hypertension)

• Consider aggressive BP reduction with continuous intravenous infusion (Class IIb, Level C evidence) 1
• Requires frequent BP monitoring every 5 minutes 1
• Critical caveat: Avoid acute SBP reduction >70 mm Hg from initial levels within the first hour, as this is associated with worse outcomes 1

SBP >180 mm Hg with Elevated Intracranial Pressure (ICP)

• Monitor ICP and maintain cerebral perfusion pressure (CPP) ≥60 mm Hg 1
• Use intermittent or continuous intravenous medications while balancing BP reduction against CPP preservation 1
• This approach prevents compromising perfusion to brain tissue surrounding the hematoma 1

Practical Implementation Strategy

Timing and Monitoring

• Initiate BP lowering within 6 hours of ICH onset for optimal benefit 1
• Use continuous intravenous agents (nicardipine is commonly studied) rather than intermittent boluses 1, 2
• Monitor BP continuously via arterial line in patients requiring continuous IV antihypertensives 1
• Reassess neurological status every 15 minutes during active BP reduction 1

Duration of Intensive Control

• Maintain target SBP for at least 7 days after ICH onset 1
• The acute phase (first 24-48 hours) is most critical for preventing hematoma expansion 1

Critical Pitfalls to Avoid

Excessive or Rapid BP Reduction

• Do not reduce SBP by >20% in the first 48 hours, as this is independently associated with renal adverse events (OR 8.99), brain ischemia (OR 22.5), and worse functional outcomes (OR 11.79 for mRS 4-6) 3
• Rapid BP decline during acute hospitalization was associated with increased mortality in retrospective studies 1
• Avoid dropping SBP >70 mm Hg within 1 hour in patients presenting with SBP ≥220 mm Hg 1

Hypotension

• Avoid SBP <140 mm Hg once target is achieved, as hypotension requiring vasopressor support is associated with renal adverse events (OR 3.36) 3
• Patients spent 54% of time below target range (SBP <140 mm Hg) in one observational study, highlighting the risk of overcorrection 3
• Maintain CPP >60 mm Hg at all times 1

Delayed Treatment

• Although INTERACT2 showed no clear relationship between time-to-treatment and outcome, earlier BP control (within 6 hours) showed trends toward better outcomes 1
• Only one-third of INTERACT2 patients achieved target SBP within 1 hour, which may have diluted treatment effect 1

Reconciling Conflicting Evidence

ATACH-2 Trial Considerations

• The ATACH-2 trial (1000 patients) targeting SBP 110-139 mm Hg showed no benefit over standard treatment (140-179 mm Hg) and was stopped for futility 4
• However, ATACH-2 had significantly higher renal adverse events (9.0% vs 4.0%, P=0.002) in the intensive group, suggesting the target may have been too aggressive 4
• The 140 mm Hg target remains the evidence-based recommendation based on INTERACT2 and multiple supporting observational studies 1

Observational Data Supporting Lower Targets

• Japanese observational data (211 patients) showed SBP <138 mm Hg in first 24 hours was associated with favorable outcomes (OR 4.36) 5
• Another Japanese cohort targeting SBP 120-160 mm Hg showed neurological deterioration in only 8.1% (below expected 15.2-25.9%) 2
• These data support the safety of the <140 mm Hg target but do not justify more aggressive reduction 5, 2

Long-Term BP Management

After Acute Phase (>7 Days)

• Transition to long-term target of <130/80 mm Hg for secondary prevention of ICH recurrence 6
• This differs from the acute target and prevents confusion between acute management (<140 mm Hg systolic) and chronic prevention (<130/80 mm Hg) 6
• Hypertension is the most important modifiable risk factor for ICH recurrence (2.1-3.7% per patient-year) 6