Antihypertensive Treatment is Subpar After ICH

LOS ANGELES, CA—Blood pressure control is a problem for patients who survive an intracerebral hemorrhage (ICH) and require antihypertensive medication, and inadequate medical therapy is mostly to blame, new data show.

The rate of uncontrolled hypertension after ICH was “strikingly high” at 64.3% in a US cohort and lower but still substantial at 32.7% in a Hong Kong cohort, according to Jonathan Rosand, MD (Massachusetts General Hospital, Boston).

Lack of BP control was explained by resistant hypertension in only about one-third of cases in both cohorts, with insufficient prescription of antihypertensive drugs accounting for the rest, he reported at the International Stroke Conference here.

“This is an observation that’s been made time and again in studies of antihypertensive cohorts around the world, and it’s at the root of this term that’s become widely applied, [which is] therapeutic inertia,” Rosand said during his presentation. “In study after study, medication intensification for patients who have an ambulatory blood pressure that’s deemed elevated is generally the exception rather than the rule in the real world.”

Most ICH survivors require at least three antihypertensive drugs for BP control, which “raises the hypothesis that perhaps early inpatient initiation of multiple agents could lead to rapid and effective control of hypertension in these cohorts,” he added, noting that a fixed-combination pill might be useful after ICH.

Daniel Hanley Jr, MD (Johns Hopkins Medicine, Baltimore, MD), one of the moderators of the session at which Rosand presented the results, said he was surprised that there was such a high rate of uncontrolled BP in ICH survivors, particularly in the US cohort, and that the reason in most patients was medication inadequacy.

“We’re not doing a good enough job with that right now and we probably could do a better job,” he commented to TCTMD. There is some question, he added, about whether patients should be started on multiple antihypertensive drugs right away or whether the number of medications should be increased gradually.

“Medications are costly, so that may be one of the reasons why it either takes longer or doesn’t happen in the United States,” Hanley said. Prior studies have shown, however, that it takes two to four medications to control BP in most people. “So I think the recommendation from the presentation that earlier use of multiple medications should be considered is a wise recommendation,” he said.

Uncontrolled Hypertension Boosts Recurrent ICH Risk

In patients who have survived an ICH, uncontrolled hypertension is common and increases the risk of a recurrent hemorrhage. Because many recurrences—about 30%—happen in the first year, getting BP under control quickly is paramount, Rosand said.

In this study, Rosand and his colleagues set out to explore contributors to uncontrolled hypertension after ICH in two independent, prospective cohorts: one that included 781 patients treated at Mass General between July 1994 and December 2015 (mean age 69.7; 53.5% men) and one that included 391 patients treated at the University of Hong Kong between January 2011 and December 2017 (mean age 65.3; 63.7% men). The analysis included patients who survived for more than 90 days after the hemorrhage and required antihypertensive treatment.

Uncontrolled hypertension was defined as a BP of 140/90 mm Hg or higher, and this was common in both the US and Hong Kong cohorts 6 months after ICH. Resistant hypertension explained 33.5% of uncontrolled BP in the US and 29.7% in Hong Kong. Medication inadequacy accounted for 66.5% and 70.4%, respectively.

Among the patients who were receiving adequate medical therapy, at least three medications were required for 60% of the US cohort and 37.2% of the Hong Kong cohort.

The strongest factors associated with needing three or more drugs were an admission systolic BP above 190 mm Hg (OR 3.46; 95% CI 2.59-4.61), a history of hypertension before ICH (OR 3.39; 95% CI 2.32-4.94), and age younger than 65 (OR 1.80; 95% CI 1.33-2.45).

Rosand noted that the study was limited by the observational design, the probable underestimation of resistant hypertension due to missing data, and the lack of information on the doses of antihypertensive drugs used and on medication adherence.

Nevertheless, the study underscores an important point about the need to better control BP after ICH, Hanley said. “Prevention of a second ICH works and ideally it ought to be used. And ideally, we shouldn’t lose patients who have the opportunity to receive prevention.”