# Blood Pressure Management in Spontaneous Intracerebral Hemorrhage — AHA/ASA 2022

## Rationale

Elevated blood pressure is common in acute ICH and is associated with hematoma expansion, neurological deterioration, and poor outcomes. Acute blood pressure lowering aims to reduce hematoma expansion while maintaining adequate cerebral perfusion.

## Blood Pressure Targets

### SBP 150-220 mmHg (Without Contraindication)

- In patients with spontaneous ICH presenting with **systolic blood pressure (SBP) between 150 and 220 mmHg** and without contraindication to acute BP treatment:
  - **Acute lowering of SBP to 140 mmHg is safe** (Class I, LOE A).
  - **Acute lowering of SBP to 140 mmHg can be effective for improving functional outcome** (Class IIa, LOE B-R).
  - Acceptable target range: **130-150 mmHg**.
  - **Avoid SBP < 130 mmHg**, as excessive lowering may be associated with renal adverse events and worse outcomes (informed by ATACH-2 trial findings).

### SBP > 220 mmHg

- In patients with spontaneous ICH presenting with **SBP > 220 mmHg**, it is reasonable to use **continuous IV infusion with close blood pressure monitoring** to reduce SBP (Class IIa, LOE C-EO).
- No specific target SBP is firmly established for this group; clinical judgment should guide the degree and speed of reduction while avoiding precipitous drops.

## Timing of Blood Pressure Treatment

- **Initiate treatment within 2 hours of ICH onset** (Class IIa, LOE B-R).
- **Achieve target SBP within 1 hour of initiating treatment** (Class IIa, LOE B-R).
- Medication titration to ensure **continuous, smooth, and sustained control** of blood pressure, avoiding peaks and large variability in SBP, can be beneficial (Class IIa, LOE B-NR).
- Blood pressure variability (large swings in SBP) is independently associated with worse outcomes and should be minimized.

## Preferred IV Antihypertensive Agents

The following IV agents are preferred for acute BP management in ICH due to their ease of titration and predictable dose-response:

| Agent | Initial Dose | Titration | Maximum |
|-------|-------------|-----------|---------|
| **Nicardipine** | 5 mg/h IV infusion | Increase by 2.5 mg/h every 5-15 min | 15 mg/h |
| **Labetalol** | 10-20 mg IV bolus over 1-2 min | Repeat every 10-15 min or 2-8 mg/min infusion | 300 mg total bolus |
| **Clevidipine** | 1-2 mg/h IV infusion | Double dose every 2-5 min | 21 mg/h |

### Agent Selection Considerations

- **Nicardipine** may provide faster and more predictable BP control than labetalol, and is particularly useful when precise titration is required.
- **Labetalol** should be avoided in patients with severe bradycardia, greater-than-first-degree heart block, decompensated heart failure, or severe reactive airway disease.
- **Clevidipine** is an alternative with rapid onset and offset; it is lipid-based and should be avoided in patients with soy or egg allergy, severe aortic stenosis, or lipid disorders.
- Nitroprusside should generally be avoided due to potential for increasing intracranial pressure.

## Monitoring

- Continuous arterial blood pressure monitoring (arterial line) is recommended for patients receiving IV antihypertensive infusions.
- Frequent neurological reassessment during acute BP lowering to detect any deterioration potentially related to cerebral hypoperfusion.

## Key Trial Evidence

- **INTERACT2 (2013):** Intensive BP lowering (target SBP < 140 mmHg within 1 hour) showed a trend toward improved functional outcomes compared with guideline-recommended treatment (target SBP < 180 mmHg). Safety was confirmed.
- **ATACH-2 (2016):** Intensive BP lowering (target SBP 110-139 mmHg) was not superior to standard treatment (target SBP 140-179 mmHg) and was associated with increased renal adverse events. This informed the recommendation to avoid SBP < 130 mmHg.
- **INTERACT3 (2023):** A bundled care approach including early intensive BP lowering to < 140 mmHg demonstrated improved functional outcomes.

## Blood Pressure Management Algorithm

```
Patient with acute spontaneous ICH
  --> Measure SBP immediately
      --> SBP 150-220 mmHg?
          --> Initiate IV antihypertensive within 2 hours of ICH onset
          --> Target SBP 140 mmHg (range 130-150 mmHg) within 1 hour
          --> Preferred agents: nicardipine, labetalol, or clevidipine
          --> Monitor via arterial line
          --> Avoid SBP < 130 mmHg
      --> SBP > 220 mmHg?
          --> Continuous IV infusion with close monitoring
          --> Gradual reduction; avoid precipitous drops
          --> Clinical judgment for target
      --> SBP < 150 mmHg?
          --> Routine aggressive BP lowering is not indicated
          --> Treat to maintain adequate cerebral perfusion
  --> Maintain smooth, sustained BP control
      --> Avoid peaks and large variability in SBP
      --> Reassess neurological status frequently
```

## Limitations

- The optimal lower limit of SBP has not been established. The recommendation to avoid SBP < 130 mmHg is based on the ATACH-2 trial safety signal, but the precise threshold for harm remains uncertain.
- Most clinical trial data are from patients with SBP 150-220 mmHg at presentation. Evidence for SBP > 220 mmHg is limited and largely expert consensus.
- The ideal duration of intensive BP control beyond the acute phase has not been established by randomized trials.
- Patients with large hematomas, elevated intracranial pressure, or those requiring surgical intervention may have different perfusion requirements; BP management should be individualized in these contexts.
