Acute Blood Pressure Management in Intracerebral Hemorrhage: Equipoise Resists an Attack.
Acute Blood Pressure Management in Intracerebral Hemorrhage: Equipoise Resists an Attack.
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DOI：
10.1161/strokeaha.116.015060
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发表时间：
2016-12
期刊：
影响因子：
8.3
通讯作者：
Selim M
中科院分区：
文献类型：
--
作者：
Butcher K;Selim M
减少急性脑出血试验）。6在后一项试验中，这可能与66%随机分配到积极治疗目标组的患者在1小时内未达到血压目标有关。然而，ATACH-II中似乎并非如此，在积极治疗组中，88%的患者实现了这一目标。一种可能性是，即使ATACH-II太晚了，对血肿扩张没有影响。最初的ATACH-II设计的入选时间窗为症状发作后3小时，后来扩展至4.5小时。7将时间窗比INTERACT-II中使用的时间窗更窄的理由是，症状发作后血肿扩大的可能性随时间而降低。因此，如果要观察到显著的治疗效果，可能需要更早地开始降压，可能在院前环境中。目前有2项关于积极与保守BP管理的大型随机对照试验，两者的主要终点均为阴性。尽管如此，在没有经过证实的药物治疗的情况下，ICH患者的急性血压降低仍然是一种生物学上合理和合理的方法，许多对该领域感兴趣的临床科学家，包括我们自己，继续倡导这种方法。当前美国心脏协会/美国卒中协会指南表明，目标SBP 140 mm Hg可有效改善功能结局（IIa类;证据等级B）。[8]因此，我们认为，某种均势仍然存在。我们认为，在ICH后患者随机接受积极与保守BP目标的额外试验，可能是在院前环境中，理想情况下包括弥散加权磁共振成像用于检测亚临床脑损伤，是有必要的。这些试验可能最终证实早期BP治疗改善结果的假设，同时也确定一些患者是否真的受到这种方法的伤害。其中一些试验正在进行中（NCT 02281838）或正在计划中。我们焦急地等待着他们的结果。
Reduction in Acute Cerebral Haemorrhage Trial). 6 In the latter trial, this may have been related to the fact that BP targets were not achieved within 1 hour in 66% of the patients randomized to the aggressive treatment target arm. This does not seem to be the case in ATACH-II, however, where this was accomplished in 88% of patients in the aggressive treatment arm. One possibility is that even the effective BP reduction seen in ATACH-II was too late to have an effect on hematoma expansion. The initial ATACH-II design had an inclusion window of 3 hours from symptom onset, and this was later expanded to 4.5 hours. 7 The rationale for the narrower window than that used in INTERACT-II was that the probability of hematoma expansion decreases with time after symptom onset. It may, therefore, be that if a significant treatment effect is to be seen, BP reduction will need to begin even earlier, potentially in the prehospital setting. There are now 2 large randomized controlled trials of aggressive versus conservative BP management, both of which had negative primary end points. Nonetheless, acute BP lowering in ICH patients remains a biologically plausible and rational approach to the one stroke type without a proven medical therapy, and many clinician scientists with an interest in the field, ourselves included, continue to advocate for this approach. Current American Heart Association/American Stroke Association guidelines indicate that a target SBP of 140 mm Hg can be effective for improving functional outcome (Class IIa; Level of Evidence B). 8 We, therefore, suggest that some equipoise persists. Additional trials where patients are randomized to aggressive versus conservative BP targets after ICH, possibly in the prehospital setting and ideally including diffusion-weighted magnetic resonance imaging for detection of subclinical brain injury, are warranted in our opinion. Such trials may ultimately confirm the hypothesis that earlier BP treatment improves outcome while also determining whether some patients are in fact harmed by this approach. Some of these trials are either ongoing (NCT02281838) or are in planning. We anxiously await their results.