Association Between Blood Pressure Control and Risk of Recurrent Intracerebral Hemorrhage.
OBJECTIVE
Intracerebral hemorrhage (ICH) is the most severe form of stroke. Survivors are at high risk of recurrence, death, and worsening functional disability.


OBJECTIVE
To investigate the association between blood pressure (BP) after index ICH and risk of recurrent ICH.


METHODS
Single-site, tertiary care referral center observational study of 1145 of 2197 consecutive patients with ICH presenting from July 1994 to December 2013. A total of 1145 patients with ICH survived at least 90 days and were followed up through December 2013 (median follow-up of 36.8 months [minimum, 9.8 months]).


METHODS
Blood pressure measurements at 3, 6, 9, and 12 months, and every 6 months thereafter, obtained from medical personnel (inpatient hospital or outpatient clinic medical or nursing staff) or via patient self-report. Exposure was characterized in 3 ways: (1) recorded systolic and diastolic measurements; (2) classification as adequate or inadequate BP control based on American Heart Association/American Stroke Association recommendations; and (3) stage of hypertension based on Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 7 criteria.


METHODS
Recurrent ICH and its location within the brain (lobar vs nonlobar).


RESULTS
There were 102 recurrent ICH events among 505 survivors of lobar ICH and 44 recurrent ICH events among 640 survivors of nonlobar ICH. During follow-up adequate BP control was achieved on at least 1 measurement by 625 patients (54.6% of total [range, 49.2%-58.7%]) and consistently (ie, at all available time points) by 495 patients (43.2% of total [range, 34.5%-51.0%]). The event rate for lobar ICH was 84 per 1000 person-years among patients with inadequate BP control compared with 49 per 1000 person-years among patients with adequate BP control. For nonlobar ICH the event rate was 52 per 1000 person-years with inadequate BP control compared with 27 per 1000 person-years for patients with adequate BP control. In analyses modeling BP control as a time-varying variable, inadequate BP control was associated with higher risk of recurrence of both lobar ICH (hazard ratio [HR], 3.53 [95% CI, 1.65-7.54]) and nonlobar ICH (HR, 4.23 [95% CI, 1.02-17.52]). Systolic BP during follow-up was associated with increased risk of both lobar ICH recurrence (HR, 1.33 per 10-mm Hg increase [95% CI, 1.02-1.76]) and nonlobar ICH recurrence (HR, 1.54 [95% CI, 1.03-2.30]). Diastolic BP was associated with increased risk of nonlobar ICH recurrence (HR, 1.21 per 10-mm Hg increase [95% CI, 1.01-1.47]) but not with lobar ICH recurrence (HR, 1.36 [95% CI, 0.90-2.10]).


CONCLUSIONS
In this observational single-center cohort study of ICH survivors, reported BP measurements suggesting inadequate BP control during follow-up were associated with higher risk of both lobar and nonlobar ICH recurrence. These data suggest that randomized clinical trials are needed to address the benefits and risks of stricter BP control in ICH survivors.
Center for Human Genetic Research, Massachusetts General Hospital, Boston2J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston3Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts Gener.
Alessandro
A
Biffi
Center for Human Genetic Research, Massachusetts General Hospital, Boston2J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston3Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts Gener.
Christopher D
CD
Anderson
Center for Human Genetic Research, Massachusetts General Hospital, Boston2J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston3Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts Gener.
Thomas W K
TW
Battey
J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston.
Alison M
AM
Ayres
J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston3Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston.
Steven M
SM
Greenberg
J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston3Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston.
Anand
A
Viswanathan
Center for Human Genetic Research, Massachusetts General Hospital, Boston2J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston3Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts Gener.
Jonathan
J
Rosand
D000368:Aged; D000959:Antihypertensive Agents / Q000627:therapeutic use; D001795:Blood Pressure Determination / Q000706:statistics & numerical data; D002543:Cerebral Hemorrhage / Q000453:epidemiology / Q000208:ethnology / Q000209:etiology* / Q000473:pathology; D005260:Female; D006801:Humans; D006973:Hypertension / Q000150:complications / Q000208:ethnology / Q000517:prevention & control*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D012008:Recurrence; D012306:Risk; D055502:Secondary Prevention / Q000379:methods; D018709:Statistics, Nonparametric; D017741:Survivors; D013997:Time Factors
D000959:Antihypertensive Agents