Dataset Information

Continuing versus Stopping Prestroke Antihypertensive Therapy in Acute Intracerebral Hemorrhage: A Subgroup Analysis of the Efficacy of Nitric Oxide in Stroke Trial.

ABSTRACT:

Background and purpose

More than 50% of patients with acute intracerebral hemorrhage (ICH) are taking antihypertensive drugs before ictus. Although antihypertensive therapy should be given long term for secondary prevention, whether to continue or stop such treatment during the acute phase of ICH remains unclear, a question that was addressed in the Efficacy of Nitric Oxide in Stroke (ENOS) trial.

Methods

ENOS was an international multicenter, prospective, randomized, blinded endpoint trial. Among 629 patients with ICH and systolic blood pressure between 140 and 220 mmHg, 246 patients who were taking antihypertensive drugs were assigned to continue (n = 119) or to stop (n = 127) taking drugs temporarily for 7 days. The primary outcome was the modified Rankin Score at 90 days. Secondary outcomes included death, length of stay in hospital, discharge destination, activities of daily living, mood, cognition, and quality of life.

Results

Blood pressure level (baseline 171/92 mmHg) fell in both groups but was significantly lower at 7 days in those patients assigned to continue antihypertensive drugs (difference 9.4/3.5 mmHg, P < .01). At 90 days, the primary outcome did not differ between the groups; the adjusted common odds ratio (OR) for worse outcome with continue versus stop drugs was .92 (95% confidence interval, .45-1.89; P = .83). There was no difference between the treatment groups for any secondary outcome measure, or rates of death or serious adverse events.

Conclusions

Among patients with acute ICH, immediate continuation of antihypertensive drugs during the first week did not reduce death or major disability in comparison to stopping treatment temporarily.

SUBMITTER: Krishnan K

PROVIDER: S-EPMC4851456 | biostudies-literature | 2016 May

REPOSITORIES: biostudies-literature

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Publications

Continuing versus Stopping Prestroke Antihypertensive Therapy in Acute Intracerebral Hemorrhage: A Subgroup Analysis of the Efficacy of Nitric Oxide in Stroke Trial.

Krishnan Kailash K Scutt Polly P Woodhouse Lisa L Adami Alessandro A Becker Jennifer L JL Cala Lesley A LA Casado Ana M AM Chen Christopher C Dineen Robert A RA Gommans John J Koumellis Panos P Christensen Hanna H Collins Ronan R Czlonkowska Anna A Lees Kennedy R KR Ntaios George G Ozturk Serefnur S Phillips Stephen J SJ Sprigg Nikola N Szatmari Szabolcs S Wardlaw Joanna M JM Bath Philip M PM

Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association 20160204 5

<h4>Background and purpose</h4>More than 50% of patients with acute intracerebral hemorrhage (ICH) are taking antihypertensive drugs before ictus. Although antihypertensive therapy should be given long term for secondary prevention, whether to continue or stop such treatment during the acute phase of ICH remains unclear, a question that was addressed in the Efficacy of Nitric Oxide in Stroke (ENOS) trial.<h4>Methods</h4>ENOS was an international multicenter, prospective, randomized, blinded endp ...[more]

PMID: 26853137

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Project description:BackgroundHigh blood pressure is associated with poor outcome after stroke. Whether blood pressure should be lowered early after stroke, and whether to continue or temporarily withdraw existing antihypertensive drugs, is not known. We assessed outcomes after stroke in patients given drugs to lower their blood pressure.MethodsIn our multicentre, partial-factorial trial, we randomly assigned patients admitted to hospital with an acute ischaemic or haemorrhagic stroke and raised systolic blood pressure (systolic 140-220 mm Hg) to 7 days of transdermal glyceryl trinitrate (5 mg per day), started within 48 h of stroke onset, or to no glyceryl trinitrate (control group). A subset of patients who were taking antihypertensive drugs before their stroke were also randomly assigned to continue or stop taking these drugs. The primary outcome was function, assessed with the modified Rankin Scale at 90 days by observers masked to treatment assignment. This study is registered, number ISRCTN99414122.FindingsBetween July 20, 2001, and Oct 14, 2013, we enrolled 4011 patients. Mean blood pressure was 167 (SD 19) mm Hg/90 (13) mm Hg at baseline (median 26 h [16-37] after stroke onset), and was significantly reduced on day 1 in 2000 patients allocated to glyceryl trinitrate compared with 2011 controls (difference -7·0 [95% CI -8·5 to -5·6] mm Hg/-3·5 [-4·4 to -2·6] mm Hg; both p<0·0001), and on day 7 in 1053 patients allocated to continue antihypertensive drugs compared with 1044 patients randomised to stop them (difference -9·5 [95% CI -11·8 to -7·2] mm Hg/-5·0 [-6·4 to -3·7] mm Hg; both p<0·0001). Functional outcome at day 90 did not differ in either treatment comparison-the adjusted common odds ratio (OR) for worse outcome with glyceryl trinitrate versus no glyceryl trinitrate was 1·01 (95% CI 0·91-1·13; p=0·83), and with continue versus stop antihypertensive drugs OR was 1·05 (0·90-1·22; p=0·55).InterpretationIn patients with acute stroke and high blood pressure, transdermal glyceryl trinitrate lowered blood pressure and had acceptable safety but did not improve functional outcome. We show no evidence to support continuing prestroke antihypertensive drugs in patients in the first few days after acute stroke.FundingUK Medical Research Council.

Project description:ImportanceHypertension is the predominant pathology underlying nonlobar intracerebral hemorrhage (ICH), and antihypertensive agents have distinct biological implications for cerebral microvasculature. It is unknown if the class of antihypertensive medications initiated after ICH affects functional outcome beyond blood pressure (BP) control.ObjectiveTo ascertain the association between the class of antihypertensive agents initiated during hospitalization and 90-day functional outcome in nonlobar ICH.Design, setting, and participantsThis cohort study uses data from the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study, a case-control cohort study investigating ICH risk factors among Hispanic, non-Hispanic Black (hereafter Black), and non-Hispanic White (hereafter White) populations at 42 US hospitals from 2010 to 2015. Data for this analysis were examined from May to September 2024. ERICH study participants were selected for the present analysis if they survived hospitalization and had available covariate and outcome data. Individuals with complications that would limit antihypertensive choice were excluded.ExposuresInitiation of angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB), calcium channel blocker, β-blocker, thiazide diuretic, and other antihypertensive medications during index hospitalization.Main outcomes and measuresPrimary outcome was a favorable functional outcome, defined as a 90-day (follow-up) modified Rankin Score score of 0 to 2 (score range: 0 [indicating no disability] to 6 [indicating death]). Mixed-effects logistic regression adjusted for demographic characteristics, medical history, ICH characteristics, BP measurement, total number of antihypertensive medications, and hospitalization site was used to calculate the odds of favorable functional outcome.ResultsOf the 1561 ERICH study participants in the analytic cohort, 1079 had nonlobar and 482 had lobar ICH. Among the 1079 participants in the nonlobar ICH group (mean [SD] age, 58.5 [12.9] years; 676 males [62.6%]; 429 Hispanic [39.8%], 388 Black [36.0%], and 262 White [24.4%] individuals), a total of 407 (37.7%) ACEIs or ARBs, 419 (38.8%) β-blockers, 503 (46.6%) calcium channel blockers, 180 (16.7%) thiazide diuretics, and 277 (25.7%) other antihypertensive classes were initiated during hospitalization (median [IQR], 3 [2-3] agents at discharge). At follow-up, 481 participants (44.6%) had a favorable functional outcome. Initiation of ACEI or ARB was associated with higher odds of favorable functional outcome (adjusted OR [AOR], 1.49; 95% CI, 1.08-2.05; P = .01). No other antihypertensive class was associated with functional outcome. Findings were consistent across several sensitivity analyses. The interaction with ACEI or ARB was mediated by the presence of radiographic features of cerebral small vessel disease (AOR, 3.04; 95% CI, 1.01-9.19; P = .049). No association with class of antihypertensive agent was observed in lobar ICH.Conclusions and relevanceThis large cohort study found that initiation of ACEI or ARB was associated with favorable 90-day functional outcomes after nonlobar ICH. This finding supports a medication class-specific benefit in hypertensive arteriopathy.

Project description:Background and Purpose- Whether to resume oral anticoagulation treatment after intracerebral hemorrhage (ICH) remains an unresolved question. Previous studies focused primarily on recurrent stroke after ICH. We sought to investigate the association between cardioembolic stroke risk, oral anticoagulation therapy resumption, and functional recovery among ICH survivors in the absence of recurrent stroke. Methods- We conducted a joint analysis of 3 observational studies: (1) the multicenter RETRACE study (German-Wide Multicenter Analysis of Oral Anticoagulation Associated Intracerebral Hemorrhage); (2) the Massachusetts General Hospital ICH study (n=166); and (3) the ERICH study (Ethnic/Racial Variations of Intracerebral Hemorrhage; n=131). We included 941 survivors of ICH in the setting of active oral anticoagulation therapy for prevention of cardioembolic stroke because of nonvalvular atrial fibrillation and without evidence of ischemic stroke and recurrent ICH at 1 year from the index event. We created univariable and multivariable models to explore associations between cardioembolic stroke risk (based on CHA2DS2-VASc scores) and functional recovery after ICH, defined as achieving modified Rankin Scale score of ≤3 at 1 year for participants with modified Rankin Scale score of >3 at discharge. Results- In multivariable analyses, the CHA2DS2-VASc score was associated with a decreased likelihood of functional recovery (odds ratio, 0.83 per 1 point increase; 95% CI, 0.79-0.86) at 1 year. Anticoagulation resumption was independently associated with a higher likelihood of recovery, regardless of CHA2DS2-VASc score (odds ratio, 1.89; 95% CI, 1.32-2.70). We found an interaction between CHA2DS2-VASc score and anticoagulation resumption in terms of association with increased likelihood of functional recovery (interaction P=0.011). Conclusions- Increasing cardioembolic stroke risk is associated with a decreased likelihood of functional recovery at 1 year after ICH, but this association was weaker among participants resuming oral anticoagulation therapy. These findings support, including recovery metrics, in future studies of anticoagulation resumption after ICH.

Project description:Background Data on the relative contribution of clinical and neuroimaging risk factors to acute ischemic stroke (AIS) versus intracerebral hemorrhage (ICH) occurring on oral anticoagulant treatment are scarce. Methods and Results Cross-sectional study was done on consecutive oral anticoagulant-treated patients presenting with AIS, transient ischemic attack (TIA), or ICH from the prospective observational NOACISP (Novel-Oral-Anticoagulants-In-Stroke-Patients)-Acute registry. We compared clinical and neuroimaging characteristics (small vessel disease markers and atherosclerosis) in ICH versus AIS/TIA (reference) using logistic regression. Among 734 patients presenting with stroke on oral anticoagulant treatment (404 [55%] direct oral anticoagulants, 330 [45%] vitamin K antagonists), 605 patients (82%) had AIS/TIA and 129 (18%) had ICH. Prior AIS/TIA, coronary artery disease, dyslipidemia, and worse renal function were associated with AIS/TIA (adjusted odds ratio [aOR] [95% CI] 0.51 [0.32-0.82], 0.48 [0.26-0.86], 0.55 [0.34-0.89], and 0.82 [0.75-0.90] per 10 mL/min). Prior ICH, older age, higher admission blood pressure, and statin treatment were associated with ICH (aOR [95% CI] 6.33 [2.87-14.04], 1.37 [1.04-1.81] per 10 years, 1.19 [1.10-1.29] per 10 mm Hg, and 1.81 [1.09-3.03]). Cerebral microbleeds and moderate-to-severe white matter hyperintensities contributed more to ICH (aOR [95% CI] 2.77 [1.34-6.18], and 2.62 [1.28-5.63]). Aortic arch, common and internal carotid artery atherosclerosis, and internal carotid artery stenosis ≥50% contributed more to AIS/TIA (aOR [95% CI] 0.54 [0.31-0.90], 0.29 [0.05-0.97], 0.48 [0.30-0.76], and 0.32 [0.13-0.67]). Conclusions In patients presenting with stroke on oral anticoagulant, AIS/TIA was 5 times more common than ICH. A high atherosclerotic burden (indicated by cardiovascular comorbidities and extracranial atherosclerosis) and prior AIS/TIA contributed more to AIS/TIA, while small vessel disease markers and prior ICH were stronger determinants for ICH. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02353585.

Dataset Information

Continuing versus Stopping Prestroke Antihypertensive Therapy in Acute Intracerebral Hemorrhage: A Subgroup Analysis of the Efficacy of Nitric Oxide in Stroke Trial.

Background and purpose

Methods

Results

Conclusions

Publications

Continuing versus Stopping Prestroke Antihypertensive Therapy in Acute Intracerebral Hemorrhage: A Subgroup Analysis of the Efficacy of Nitric Oxide in Stroke Trial.

Similar Datasets

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