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Nithimathachoke A, Tiensawang S, Deechot N, Sutaparak C, Sriamornrattanakul K. A randomized controlled trial: Comparing blood pressure reduction in hyperacute phase of spontaneous intracerebral hemorrhage by continuous nicardipine infusion with or without a preceding nicardipine bolus dose. Heliyon 2023; 9:e22812. [PMID: 38125548 PMCID: PMC10731089 DOI: 10.1016/j.heliyon.2023.e22812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/13/2023] [Accepted: 11/20/2023] [Indexed: 12/23/2023] Open
Abstract
Objectives To determine whether addition of an intravenous bolus dose before continuous nicardipine infusion would improve blood pressure reduction in the hyperacute phase in patients with spontaneous intracerebral hemorrhage (ICH). Design Double-blind randomized controlled trial. Setting One academic emergency department (ED) in Bangkok, Thailand. Participants Adult patients with spontaneous ICH presented to the ED between June 30, 2022, and July 15, 2023. Interventions The bolus group (n = 31) received an intravenous bolus dose of nicardipine before nicardipine continuous infusion, whereas the non-bolus group (n = 31) was given a placebo and nicardipine continuous infusion. Main outcomes Systolic blood pressure (SBP) within the first hour (being measured every 5 min), neurological deterioration, and infusion dosage at 60 min were assessed. Results Basic characteristic features including the mean baseline SBP were not significantly different between the two groups. At 10 min after treatment initiation, the bolus group had a significant decrease in SBP (32.1 ± 13.6 vs 22.3 ± 18.5 mmHg; p-value = 0.020). Moreover, the target SBP of 180 mmHg could be achieved within 10 min in the bolus group compared with 15 min in the non-bolus group. However, the overall mean SBPs were not significantly different, with 152 ± 12 mmHg in the bolus group compared with 150 ± 15 mmHg in the non-bolus group (p-value = 0.564). None of the patients in both groups had neurological deterioration over the first hour of the treatment. The infusion dosages of nicardipine at 1 h were 6.2 mg/h (5.9, 7.7 mg/h) and 6.8 mg/h (5.9, 8.4 mg/h) in the bolus and non-bolus groups, respectively (p-value = 0.618). Conclusions Administering a 1-mg bolus dose of nicardipine before continuous nicardipine infusion notably reduces SBP at 10 min. However, the overall SBP does not exhibit a significant decline during the hyperacute phase of spontaneous intracerebral hemorrhage.
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Affiliation(s)
- Adisak Nithimathachoke
- Department of Emergency Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Thailand
| | - Supatpinee Tiensawang
- Department of Emergency Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Thailand
| | - Natradee Deechot
- Department of Emergency Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Thailand
| | | | - Kitiporn Sriamornrattanakul
- Neurosurgery Unit, Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Thailand
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2
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Nash PS, Best JG, Ambler G, Wilson D, Banerjee G, Hostettler IC, Seiffge D, Cohen H, Yousry TA, Salman RAS, Lip GYH, Brown MM, Muir KW, Houlden H, Jäger HR, Werring DJ. Associations of renal function with cerebral small vessel disease and functional outcome in acute intracerebral haemorrhage: A hospital-based prospective cohort study. J Neurol Sci 2023; 452:120743. [PMID: 37531792 DOI: 10.1016/j.jns.2023.120743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/02/2023] [Accepted: 07/26/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND Intracerebral haemorrhage (ICH) is a severe clinical consequence of cerebral small vessel disease (SVD), but associations between renal impairment and SVD in patients with ICH have not been fully characterised. METHODS Using data from the CROMIS-2 ICH observational study, we compared SVD neuroimaging markers and total burden (score 0-3) identified using CT brain imaging in patients with and without renal impairment (estimated glomerular filtration rate, eGFR<60). We assessed functional outcome at 6-month follow-up using the modified Rankin scale. RESULTS 1027 participants were included (mean age 72.8, 57.1% male); 274 with and 753 without renal impairment. 18.7% of the eGFR<60 group had moderate-to-severe SVD burden (score 2-3), compared with 14.0% of those with eGFR>60 (p = 0.039). SVD burden was associated with renal impairment after adjusting for hypertension (OR 1.36, 95% CI 1.04-1.77, p = 0.023), but not after adjusting for age. Cerebral atrophy was more prevalent in patients with eGFR<60 (81.2% vs. 72.0%, p = 0.002), as were WMH (45.6% vs. 36.6%, p = 0.026). Neither was associated with renal function after adjusting for age and vascular risk factors. Renal impairment was associated with functional outcome (OR 0.65, 95% CI 0.47-0.89, p = 0.007), but not after adjusting for age, pre-morbid function and comorbidities (OR 0.95, 95% CI 0.65-1.38, p = 0.774). CONCLUSION In acute ICH, renal impairment is associated with a higher cerebral SVD burden independent of hypertension, but not age. Reduced eGFR is associated with worse functional outcome, but not independent of age and comorbidities. Since CT has limited sensitivity to detect SVD severity and distribution, further studies including MRI are needed.
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Affiliation(s)
- Philip S Nash
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK
| | - Jonathan G Best
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, Gower Street, UK
| | - Duncan Wilson
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK
| | - Gargi Banerjee
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK
| | - Isabel C Hostettler
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK; Neurosurgical Department, Canton Hospital St. Gallen, St. Gallen, Switzerland
| | - David Seiffge
- Department of Neurology and Stroke Center, Inselspital, Bern, Switzerland
| | - Hannah Cohen
- Department of Haematology, University College London, Chenies Mews, UK
| | - Tarek A Yousry
- Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London, UK
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; and Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Martin M Brown
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, UK
| | - Henry Houlden
- Department of Molecular Neuroscience, UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Hans Rolf Jäger
- Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London, UK
| | - David J Werring
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK.
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3
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Yu Y, Gong Y, Hu B, Ouyang B, Pan A, Liu J, Liu F, Shang XL, Yang XH, Tu G, Wang C, Ma S, Fang W, Liu L, Liu J, Chen D. Expert consensus on blood pressure management in critically ill patients. JOURNAL OF INTENSIVE MEDICINE 2023; 3:185-203. [PMID: 37533806 PMCID: PMC10391579 DOI: 10.1016/j.jointm.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/02/2023] [Accepted: 06/08/2023] [Indexed: 08/04/2023]
Affiliation(s)
- Yuetian Yu
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200001, China
| | - Ye Gong
- Department of Critical Care Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Bo Hu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China
| | - Bin Ouyang
- Department of Critical Care Medicine, The First Affiliated Hospital of SunYatsen University, Guangzhou 510080, Guangdong, China
| | - Aijun Pan
- Department of Critical Care Medicine, The First Affiliated Hospital of USTC, Division of Life Science and Medicine, University of Science and Technology of China, Hefei 230001, Anhui, China
| | - Jinglun Liu
- Department of Emergency Medicine and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Fen Liu
- Department of Critical Care Medicine, The First Affiliated Hospital of Nanchang University, Nanchang 330000, Jiangxi, China
| | - Xiu-Ling Shang
- Department of Critical Care Medicine, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Center for Critical Care Medicine, Fujian Provincial Key Laboratory of Critical Care Medicine, Fuzhou 350001 Fujian, China
| | - Xiang-Hong Yang
- Department of Intensive Care Unit, Emergency & Intensive Care Unit Center, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou 310014 Zhejiang, China
| | - Guowei Tu
- Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Changsong Wang
- Department of Critical Care Medicine, the First Affiliated Hospital of Harbin Medical University, Harbin 150001, Heilongjiang, China
| | - Shaolin Ma
- Department of Critical Care Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Wei Fang
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Shandong First Medical University, Jinan, 250014 Shandong, China
| | - Ling Liu
- Department of Critical Care Medicine, Jiangsu Provincial Key Laboratory of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009 Jiangsu, China
| | - Jiao Liu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Dechang Chen
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
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4
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Chakraborty D. Intracerebral Hemorrhage in Renal Compromised State: How is the Combination? Ann Indian Acad Neurol 2023; 26:374-375. [PMID: 37970297 PMCID: PMC10645200 DOI: 10.4103/aian.aian_612_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 07/15/2023] [Indexed: 11/17/2023] Open
Affiliation(s)
- Debabrata Chakraborty
- Department of Neurology, Apollo Multispeciality Hospitals, Kolkata, West Bengal, India
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5
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Intravenous nicardipine for Japanese patients with acute intracerebral hemorrhage: an individual participant data analysis. Hypertens Res 2023; 46:75-83. [PMID: 36224285 PMCID: PMC9747609 DOI: 10.1038/s41440-022-01046-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 08/28/2022] [Accepted: 09/09/2022] [Indexed: 02/03/2023]
Abstract
The effects of acute systolic blood pressure levels achieved with continuous intravenous administration of nicardipine for Japanese patients with acute intracerebral hemorrhage on clinical outcomes were determined. A systematic review and individual participant data analysis of articles were performed based on prospective studies involving adults developing hyperacute intracerebral hemorrhage who were treated with intravenous nicardipine. Outcomes included death or disability at 90 days, defined as the modified Rankin Scale score of 4-6, and hematoma expansion, defined as an increase 6 mL or more from baseline to 24 h computed tomography. Of the total 499 Japanese patients (age 64.9 ± 11.8 years, 183 women, initial BP 203.5 ± 18.3/109.1 ± 17.2 mmHg) studied, death or disability occurred in 35.6%, and hematoma expansion occurred in 15.6%. Mean hourly systolic blood pressure during the initial 24 h was positively associated with death or disability (adjusted odds ratio 1.25, 95% confidence interval 1.03-1.52 per 10 mmHg) and hematoma expansion (1.49, 1.18-1.87). These odds ratios were relatively high as compared to the reported ones for overall global patients of this individual participant data analysis [1.12 (95% confidence interval 1.00-1.26) and 1.16 (1.02-1.32), respectively]. In conclusion, lower levels of systolic blood pressure by continuous intravenous nicardipine were associated with lower risks of hematoma expansion and 90-day death or disability in Japanese patients with hyperacute intracerebral hemorrhage. The impact of systolic blood pressure lowering on better outcome seemed to be stronger in Japanese patients than the global ones.
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6
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Zhai Y, Che B, Liu Y, Peng H, Wang A, Peng Y, Chen J, Zhang Y, Xu T, Zhong C, He J. Effect of Immediate Antihypertensive Treatment on Clinical Outcomes in Acute Ischemic Stroke Patients With Different Renal Function Status. Hypertension 2023; 80:204-213. [PMID: 36353999 DOI: 10.1161/hypertensionaha.122.20202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND It remains unclear whether different blood pressure management strategies should be administered for acute stroke patients with or without impaired renal function. We conducted a secondary analysis of the CATIS trial (China Antihypertensive Trial in Acute Ischemic Stroke) to investigate the effect of early antihypertensive treatment among patients with acute ischemic stroke according to the baseline renal function assessed by estimated glomerular filtration rates (eGFR). METHODS The CATIS trial randomly assigned 4071 acute ischemic stroke patients with systolic blood pressure between 140 and 220 mm Hg to receive antihypertensive treatment or to discontinue all antihypertensive medications during hospitalization. A primary outcome (composite outcome of death and major disability) and secondary outcomes were compared between antihypertensive treatment and control groups by baseline renal function levels of eGFR values of <60, 60 to 89, and ≥90 mL/min per 1.73 m2. RESULTS At day 14 or hospital discharge, the primary outcome was not significantly different between the antihypertensive treatment and control groups in each subgroup stratified by renal function status (P=0.98 for homogeneity), and the odds ratios (95% CIs) were 1.23 (0.76-2.02) in patients with eGFR <60 mL/min per 1.73 m2, 0.94 (0.75-1.19) in patients with eGFR values of 60-89 mL/min per 1.73 m2, and 1.04 (0.88-1.24) in patients with eGFR ≥90 mL/min per 1.73 m2, respectively. In addition, early antihypertensive treatment was not associated with secondary clinical outcomes by baseline renal function (P>0.05 for all homogeneity). CONCLUSIONS Early antihypertensive treatment had a neutral effect on clinical outcomes in ischemic stroke patients with different renal function status. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique Identifier: NCT01840072.
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Affiliation(s)
- Yujia Zhai
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Suzhou Medical College of Soochow University, China (Y.Z., B.C., H.P., A.W., Y.Z., T.X., C.Z.)
| | - Bizhong Che
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Suzhou Medical College of Soochow University, China (Y.Z., B.C., H.P., A.W., Y.Z., T.X., C.Z.)
| | - Yang Liu
- Department of Cardiology, First Affiliated Hospital of Soochow University, Suzhou, China (Y.L.).,Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA (Y.L., J.C., C.Z., J.H.)
| | - Hao Peng
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Suzhou Medical College of Soochow University, China (Y.Z., B.C., H.P., A.W., Y.Z., T.X., C.Z.)
| | - Aili Wang
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Suzhou Medical College of Soochow University, China (Y.Z., B.C., H.P., A.W., Y.Z., T.X., C.Z.)
| | - Yanbo Peng
- Department of Neurology, Affiliated Hospital of North China University of Science and Technology, Hebei, China (Y.P.)
| | - Jing Chen
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA (Y.L., J.C., C.Z., J.H.).,Department of Medicine, Tulane University School of Medicine, New Orleans, LA, (J.C., J.H.)
| | - Yonghong Zhang
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Suzhou Medical College of Soochow University, China (Y.Z., B.C., H.P., A.W., Y.Z., T.X., C.Z.)
| | - Tan Xu
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Suzhou Medical College of Soochow University, China (Y.Z., B.C., H.P., A.W., Y.Z., T.X., C.Z.)
| | - Chongke Zhong
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Suzhou Medical College of Soochow University, China (Y.Z., B.C., H.P., A.W., Y.Z., T.X., C.Z.).,Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA (Y.L., J.C., C.Z., J.H.)
| | - Jiang He
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA (Y.L., J.C., C.Z., J.H.).,Department of Medicine, Tulane University School of Medicine, New Orleans, LA, (J.C., J.H.)
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7
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Wan Y, Guo H, Bi R, Chen S, Shen J, Li M, Xia Y, Zhang L, Sun Z, Chen X, Cai Z, Wang Z, Gong D, Xu J, Zhu D, Hu B, He Q. Clinical and Prognostic Characteristics of Recurrent Intracerebral Hemorrhage: A Contrast to First-Ever ICH. Front Aging Neurosci 2022; 14:860571. [PMID: 35493945 PMCID: PMC9047504 DOI: 10.3389/fnagi.2022.860571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 02/28/2022] [Indexed: 11/18/2022] Open
Abstract
This study aimed to compare clinical and prognostic characteristics between recurrent and first-ever ICH. Four thousand twelve patients entered the study, and 64% of them were male. The median age is 62 years (interquartile range, 55–71). Among them, 3,750 (93.5%) patients had no experience of previous ICH, and 262 (6.5%) patients were considered as recurrent ICH. We compared demographic data, baseline clinical characteristics, imaging information, hematological parameters, and clinical outcomes between recurrent and first-ever ICH. We found that recurrent ICH was significantly associated with older age, more frequent history of ischemic heart disease, ischemic stroke, hypertension, and hyperlipidemia, while patients with recurrent ICH had previously received more antihypertensive therapy, and showed lower admission blood pressure (median, 160 vs. 167 mmHg) and higher baseline of National Institute of Health stroke scale (NIHSS) score (median, 10 vs. 9). We also demonstrated that recurrent ICH was an independent risk factor of 3-month function dependence after adjusting for many potentially competitive risk factors.
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Affiliation(s)
- Yan Wan
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hongxiu Guo
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rentang Bi
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shaoli Chen
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jing Shen
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Man Li
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuanpeng Xia
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lei Zhang
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhou Sun
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaolu Chen
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhuoyuan Cai
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhaowei Wang
- Department of Neurology, Qianjiang Central Hospital, Qianjiang, China
| | - Daokai Gong
- Department of Neurology, Jingzhou Central Hospital, Jingzhou, China
| | - Jingwen Xu
- Department of Neurology, Honghu People’s Hospital, Honghu, China
| | - Dongya Zhu
- School of Pharmacy, Nanjing Medical University, Nanjing, China
| | - Bo Hu
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Bo Hu,
| | - Quanwei He
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Quanwei He,
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Controlling blood pressure soon after intracerebral hemorrhage: The SAMURAI-ICH Study and its successors. Hypertens Res 2022; 45:583-590. [PMID: 35260801 PMCID: PMC8923997 DOI: 10.1038/s41440-022-00866-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 01/11/2022] [Indexed: 12/02/2022]
Abstract
The impact of acute therapy for intracerebral hemorrhage (ICH) lags far behind that for acute ischemic stroke. Intensive blood pressure lowering is a promising therapeutic strategy for acute ICH, especially for East Asian patients whose etiological mechanism is more commonly hypertension than that of patients in the Western population. A multicenter, prospective, observational study named the Stroke Acute Management with Urgent Risk-factor Assessment and Improvement-IntraCerebral Hemorrhage (SAMURAI-ICH) study, involving 211 patients from ten Japanese stroke centers, was performed to elucidate the safety and feasibility of blood pressure lowering to 160 mmHg or less in acute ICH patients using intravenous nicardipine. When we started the study, intravenous nicardipine was not officially approved for hyperacute ICH patients in Japan. The SAMURAI-ICH study was also a pilot study to judge the feasibility of participation by many Japanese investigators in an international, randomized, controlled trial named the Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH)−2 trial. The SAMURAI-ICH study, ATACH-2 trial, and their combined individual participant data meta-analysis produced several new interesting findings on how to control blood pressure levels in acute ICH patients. Some of the findings are introduced in the present review article. ![]()
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9
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Yu G, Cheng J, Jiang Y, Li H, Li X, Chen J. Intensive Systolic Blood Pressure Lowering and Kidney Disease Progression in IgA Nephropathy: A Cohort Study. Front Med (Lausanne) 2022; 9:813603. [PMID: 35252253 PMCID: PMC8890476 DOI: 10.3389/fmed.2022.813603] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 01/10/2022] [Indexed: 12/04/2022] Open
Abstract
Background Hypertension has been shown to be an important risk factor in IgA nephropathy (IgAN). The 2021 the Kidney Disease Improving Global Outcomes (KDIGO) Guideline proposes a target systolic blood pressure (SBP) of less than 120 mmHg in patients with Chronic Kidney Disease (CKD) not receiving dialysis. However, whether lowering SBP from <140– <120 mm Hg is renoprotective is unknown. This study aims to evaluate the association of SBP and the progression of IgAN, then explore whether lowering SBP from <140– <120 mm Hg is renoprotective. Methods Overall, 2,240 patients with IgAN were enrolled in this study. Cox proportional hazards models and restricted cubic splines were used to estimate the associations between SBP and kidney failure events which are defined as 50% estimated glomerular filtration rate (eGFR) decline or kidney failure. Results After a median follow-up of 30.05 months, 217 (9.69%) patients reached composite kidney failure events. The association of SBP and kidney failure events showed a linear relationship. The risk of kidney failure events was greater with higher SBP. Compared with SBP <120 mm Hg, the hazard ratio was 1.85 (1.16–2.97, p = 0.010) for SBP <140 mm Hg after adjustment for traditional risk factors. The renoprotective benefits of therapy targeting SBP <120 mm Hg from SBP <140 mm Hg was detectable within the subgroup with proteinuria >1.0 g/d, CKD 1-3a stage, but not those with proteinuria ≤ 1.0 g/d and CKD 3b-4 stage. Conclusions In patients with IgAN, SBP was independently associated with composite kidney failure events. Lowering SBP from <140– <120 mm Hg was renoprotective.
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Affiliation(s)
- Guizhen Yu
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Kidney Disease Preventsion and Control Technology, Hangzhou, China.,National Key Clinical Department of Kidney Diseases, Hangzhou, China.,Institute of Nephrology, Zhejiang University, Hangzhou, China.,Third Grade Laboratory Under the National State, Administration of Traditional Chinese Medicine, Hangzhou, China
| | - Jun Cheng
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Kidney Disease Preventsion and Control Technology, Hangzhou, China.,National Key Clinical Department of Kidney Diseases, Hangzhou, China.,Institute of Nephrology, Zhejiang University, Hangzhou, China.,Third Grade Laboratory Under the National State, Administration of Traditional Chinese Medicine, Hangzhou, China
| | - Yan Jiang
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Kidney Disease Preventsion and Control Technology, Hangzhou, China.,National Key Clinical Department of Kidney Diseases, Hangzhou, China.,Institute of Nephrology, Zhejiang University, Hangzhou, China.,Third Grade Laboratory Under the National State, Administration of Traditional Chinese Medicine, Hangzhou, China
| | - Heng Li
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Kidney Disease Preventsion and Control Technology, Hangzhou, China.,National Key Clinical Department of Kidney Diseases, Hangzhou, China.,Institute of Nephrology, Zhejiang University, Hangzhou, China.,Third Grade Laboratory Under the National State, Administration of Traditional Chinese Medicine, Hangzhou, China
| | - Xiayu Li
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Kidney Disease Preventsion and Control Technology, Hangzhou, China.,National Key Clinical Department of Kidney Diseases, Hangzhou, China.,Institute of Nephrology, Zhejiang University, Hangzhou, China.,Third Grade Laboratory Under the National State, Administration of Traditional Chinese Medicine, Hangzhou, China
| | - Jianghua Chen
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Kidney Disease Preventsion and Control Technology, Hangzhou, China.,National Key Clinical Department of Kidney Diseases, Hangzhou, China.,Institute of Nephrology, Zhejiang University, Hangzhou, China.,Third Grade Laboratory Under the National State, Administration of Traditional Chinese Medicine, Hangzhou, China
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Moullaali TJ, Wang X, Sandset EC, Woodhouse LJ, Law ZK, Arima H, Butcher KS, Chalmers J, Delcourt C, Edwards L, Gupta S, Jiang W, Koch S, Potter J, Qureshi AI, Robinson TG, Al-Shahi Salman R, Saver JL, Sprigg N, Wardlaw JM, Anderson CS, Bath PM. Early lowering of blood pressure after acute intracerebral haemorrhage: a systematic review and meta-analysis of individual patient data. J Neurol Neurosurg Psychiatry 2022; 93:6-13. [PMID: 34732465 PMCID: PMC8685661 DOI: 10.1136/jnnp-2021-327195] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 09/22/2021] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To summarise evidence of the effects of blood pressure (BP)-lowering interventions after acute spontaneous intracerebral haemorrhage (ICH). METHODS A prespecified systematic review of the Cochrane Central Register of Controlled Trials, EMBASE and MEDLINE databases from inception to 23 June 2020 to identify randomised controlled trials that compared active BP-lowering agents versus placebo or intensive versus guideline BP-lowering targets for adults <7 days after ICH onset. The primary outcome was function (distribution of scores on the modified Rankin scale) 90 days after randomisation. Radiological outcomes were absolute (>6 mL) and proportional (>33%) haematoma growth at 24 hours. Meta-analysis used a one-stage approach, adjusted using generalised linear mixed models with prespecified covariables and trial as a random effect. RESULTS Of 7094 studies identified, 50 trials involving 11 494 patients were eligible and 16 (32.0%) shared patient-level data from 6221 (54.1%) patients (mean age 64.2 [SD 12.9], 2266 [36.4%] females) with a median time from symptom onset to randomisation of 3.8 hours (IQR 2.6-5.3). Active/intensive BP-lowering interventions had no effect on the primary outcome compared with placebo/guideline treatment (adjusted OR for unfavourable shift in modified Rankin scale scores: 0.97, 95% CI 0.88 to 1.06; p=0.50), but there was significant heterogeneity by strategy (pinteraction=0.031) and agent (pinteraction<0.0001). Active/intensive BP-lowering interventions clearly reduced absolute (>6 ml, adjusted OR 0.75, 95%CI 0.60 to 0.92; p=0.0077) and relative (≥33%, adjusted OR 0.82, 95%CI 0.68 to 0.99; p=0.034) haematoma growth. INTERPRETATION Overall, a broad range of interventions to lower BP within 7 days of ICH onset had no overall benefit on functional recovery, despite reducing bleeding. The treatment effect appeared to vary according to strategy and agent. PROSPERO REGISTRATION NUMBER CRD42019141136.
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Affiliation(s)
- Tom J Moullaali
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Xia Wang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Else Charlotte Sandset
- Department of Neurology, Oslo University Hospital, Oslo, Norway.,Research and Development Department, The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Lisa J Woodhouse
- Stroke Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Zhe Kang Law
- Stroke Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK.,National University of Malaysia, Kuala Lumpur, Malaysia
| | - Hisatomi Arima
- Department of Preventive Medicine and Public Health, Fukuoka University, Fukuoka, Japan
| | - Kenneth S Butcher
- Prince of Wales Clinical School, University of New South Wales, Randwick, New South Wales, Australia
| | - John Chalmers
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Candice Delcourt
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Neurology Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Central Clinical School, the University of Sydney, Sydney, New South Wales, Australia
| | - Leon Edwards
- Neurology Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Central Clinical School, the University of Sydney, Sydney, New South Wales, Australia
| | - Salil Gupta
- Department of Neurology, Army Hospital Research and Referral, New Delhi, India
| | - Wen Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.,The Shaanxi Cerebrovascular Disease Clinical Research Center, Xi'an, China
| | - Sebastian Koch
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - John Potter
- Stroke Research Group, Norfolk and Norwich University Hospital, UK.,Norwich Medical School, University of East Anglia, UK
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO
| | - Thompson G Robinson
- University of Leicester, Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, Leicester, UK
| | | | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, UCLA, Los Angeles, California, USA
| | - Nikola Sprigg
- Stroke Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia .,Prince of Wales Clinical School, University of New South Wales, Randwick, New South Wales, Australia.,Neurology Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,The George Institute China at Peking University Health Science Center, Beijing, PR China
| | - Philip M Bath
- Stroke Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Tanaka K, Toyoda K. Clinical Strategies Against Early Hematoma Expansion Following Intracerebral Hemorrhage. Front Neurosci 2021; 15:677744. [PMID: 34526875 PMCID: PMC8435629 DOI: 10.3389/fnins.2021.677744] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 08/05/2021] [Indexed: 02/01/2023] Open
Abstract
Hematoma volume is the strongest predictor of morbidity and mortality after intracerebral hemorrhage. Protection against early hematoma growth is therefore the mainstay of therapeutic intervention for acute intracerebral hemorrhage, but the current armamentarium is restricted to early blood pressure lowering and emergent reversal for anticoagulant agents. Although intensive lowering of systolic blood pressure to <140 mmHg appears likely to prevent hematoma growth, two recent randomized trials, INTERACT-2 and ATACH-2, demonstrated non-significant trends of reduced hematoma enlargement by intensive blood pressure control, with only a small magnitude of benefit or no benefit for clinical outcomes. While oral anticoagulants can be immediately reversed by prothrombin complex concentrate, or the newly developed idarucizumab for direct thrombin inhibitor or andexanet for factor Xa inhibitors, the situation regarding reversal of antiplatelet agents is not yet quite as advanced. However, considering at most the approximately 10% rate of anticoagulant use among patients with intracerebral hemorrhage, what is most essential for patients with intracerebral hemorrhage in general is early hemostatic therapy. Tranexamic acid may safely reduce hematoma expansion, but its hemostatic effect was insufficient to be translated into improved functional outcomes in the TICH-2 randomized trial with 2,325 participants. In this context, recombinant activated factor VII (rFVIIa) is a candidate to be added to the armory against hematoma enlargement. The FAST, a phase 3 trial that compared doses of 80 and 20 μg/kg rFVIIa with placebo in 841 patients within 4 h after the stroke onset, showed a significant reduction in hematoma growth with rFVIIa treatment, but demonstrated no significant difference in the proportion of patients with severe disability or death. However, a post hoc analysis of the FAST trial suggested a benefit of rFVIIa in a target subgroup of younger patients without extensive bleeding at baseline when treated earlier after stroke onset. The FASTEST trial is now being prepared to determine this potential benefit of rFVIIa, reflecting the pressing need to develop therapeutic strategies against hematoma enlargement, a powerful but modifiable prognostic factor in patients with intracerebral hemorrhage.
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Affiliation(s)
- Kanta Tanaka
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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