Intracerebral Hemorrhage: Intracerebral Hemorrhage (ICH) - Case - PowerPoint PPT Presentation

Intracerebral Hemorrhage: Intracerebral Hemorrhage (ICH) - Case Acute and Long-Term Blood Pressure Management • 55 yo construction exec – Poorly controlled hypertension J. Claude Hemphill III, MD, MAS – Slumps over table at board meeting Kenneth Rainin Chair in Neurocritical Care • Arrives at ED 30 min after onset Professor of Neurology and Neurological Surgery – GCS 9 University of California, San Francisco – BP 225/110 Chief of Neurology, San Francisco General Hospital • What do you do with the BP? Past-President, Neurocritical Care Society – Now? UC SF – Later? Disclosures NEUROCRITICAL Research Support: NIH/NINDS; Cerebrotech Medical CARE PROGRAM Stock (options): Ornim 2015 AHA ICH Guidelines (used IV nicardipine infusions) Page 1

ATACH 2 • N=1000 – Worldwide – 56.2% of participants were Asian – More than half had GCS=15 – Median hematoma volume ~10 cc • Intervention – intravenous nicardipine infusion for 24 hours to meet systolic blood pressure target • Outcome – unable to walk or worse – 38.7% in SBP < 140 mmHg group • Difference in Blood Pressure – 37.1% in SBP < 180 mmHg group • No difference in outcome • Trend towards more adverse events at 3 months in < 140 mmHg group (esp renal [posthoc]) Qureshi NEJM 2016 Qureshi NEJM 2016 2015 AHA ICH Guidelines New Definition of Hypertension • American Heart Association recently dramatically revised its definition of high blood pressure and guidelines for management. – Whelton JACC 2017 Page 2

What About ICH? BP in ICH – Practical Considerations • High blood pressure is – The most common cause of ICH – Is present in most patients with acute ICH regardless of cause of ICH – Is the most important target for primary and secondary prevention of ICH • Acute BP treatment – May not be as beneficial as we hoped – Has not been compared against “no treatment” • “Update” to 2015 AHA/ASA ICH Guidelines as a result of ATACH2 – May be more complex than we hoped • So what is the target now? » Variability may be bad (Manning Lancet Neurol 2014)  At UCSF and ZSFG we have changed to SBP < 160 mmHg » One size may not fit all – Precision Medicine needed • Example in periop care: Futier JAMA 2017 Whelton JACC 2017 BP in ICH – Practical Considerations What to Do? • Acute BP Management in ICH – Lower the BP – Select an intermediate target. » SBP < 160 mmHg for at least 3 days? • Long-term BP Management in ICH – Select a target. < 130/80 mmHg in most cases – Discharge patient on BP meds and write the target in the chart – Recognize high BP in the office and start treatment (time to dispense with notion of “white coat” hypertension) Page 3