Antihypertensive Medication After Intracerebral Hemorrhage [Neurosurgery Wiki]

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====== Antihypertensive Medication After Intracerebral Hemorrhage ======

===== Latest PubMed Articles =====

{{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/1riwIKvlTlJsFrHvq4UEBaTgNG-R1vheHV5AHH95XGS-kNhA1u/?limit=15&utm_campaign=pubmed-2&fc=20250405064845}}

==== 🧠 1. Acute Phase Management (First Hours to Days) ====
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=== 🎯 Goal: Reduce hematoma expansion and improve outcomes ===

**Target Blood Pressure (BP):**

  * SBP 150–220 mmHg → Lower to **<140 mmHg** is generally safe and may improve outcomes (AHA/ASA 2022)
  * SBP >220 mmHg → Consider aggressive reduction with ICU-level monitoring

**IV Antihypertensives:**

^ Drug         ^ Class           ^ Notes                                    ^
| Labetalol     | α/β-blocker     | Often first-line; good for rapid BP control |
| Nicardipine   | Calcium channel blocker | Preferred for titratable infusion         |
| Clevidipine   | Calcium channel blocker | Short half-life, easily adjustable        |
| Esmolol       | β1-selective blocker | Useful for short-term, fast-acting control |
| Hydralazine   | Direct vasodilator | Less predictable; not first-line            |

**Avoid**: Overly rapid BP drops, especially with elevated intracranial pressure (ICP)
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==== 🔁 2. Secondary Prevention (Long-Term Management) ====
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=== 🎯 Goal: Prevent recurrent ICH and vascular events ===

**BP Target**:  
  * Long-term: **SBP <130 mmHg**
  * Avoid SBP <110 mmHg (risk of hypoperfusion)

**Preferred Antihypertensive Classes**:

^ Class              ^ Example             ^ Notes                                   ^
| ACE inhibitors     | Enalapril, Ramipril | Good stroke prevention evidence         |
| ARBs               | Losartan, Candesartan | Well tolerated alternative to ACEi      |
| Thiazide diuretics | Hydrochlorothiazide | Often used in combo therapy             |
| Calcium channel blockers | Amlodipine     | Useful as monotherapy or in combinations |

**Key Trials:**
  * **[[PROGRESS Trial]]** – [[Perindopril]] ± [[indapamide]] reduced stroke recurrence
  * **[[INTERACT 2]] / [[ATACH]]-II** – BP lowering in acute ICH is safe and may improve outcomes
</WRAP>
 
==== 📌 Clinical Pearls ====
  * Titrate IV to oral meds with continuous monitoring
  * Consider [[Spontaneous Intracerebral Hemorrhage Etiology]] (hypertensive vs amyloid-related) for long-term goals
  * Tailor treatment to age, comorbidities, renal function, and prior drug response

====== TRICH Score ======

In a  [[prospective cohort study]] with external [[validation study]] components, the authors used data from a longitudinal ICH [[registry]] (2011–2022) for [[score]] [[development]] and validated the model [[prospective]]ly in three independent hospitals (2020–2022)
((So CH, Yeung C, Ho RW, Hou QH, Sum CHF, Leung W, Wong YK, Liu KCR, Kwan HH, Fok J, Yip EK, Sheng B, Yap DY, Leung GKK, Chan KH, Lau GKK, Teo KC. Triple Antihypertensive Medication [[Prediction Score]] After [[Intracerebral Hemorrhage]] (the TRICH Score). Neurology. 2025 May 13;104(9):e213560. doi: 10.1212/WNL.0000000000213560. Epub 2025 Apr 4. PMID: 40184593.))

The study aims to develop and validate a clinical score (the **TRICH score**) to predict the need for **≥3 antihypertensive medications** three months after [[intracerebral hemorrhage]] (ICH), to guide early and individualized [[blood pressure management]].

**Clinically Relevant Tool:** The TRICH score addresses a clear clinical need: stratifying patients by future antihypertensive needs post-ICH.

- **Well-Defined Cohorts:** The development and validation cohorts are clearly defined and separate, lending credibility to the generalizability within the studied population.

- **Statistical Rigor:** The use of **[[multivariate logistic regression]]**, β-coefficients for score construction, and **[[AUC]]** for model performance are standard and appropriate.

- **Good Discrimination:** The TRICH score achieved a c-statistic of 0.79 in the development and 0.76 in the validation cohort, indicating good predictive performance.

- **Subgroup Analyses:** The study explores performance in subgroups (e.g., uncontrolled hypertension vs controlled, CAA vs non-CAA), which is useful for clinical interpretation.

=== Limitations ===  

- **Ethnic Homogeneity:** All participants were from Hong Kong hospitals, likely representing predominantly Han Chinese patients. This limits external validity, especially in multiethnic or Western populations.

- **Short Follow-up:** The score is tailored to predict medication needs at 3 months. It remains unclear whether it has predictive power for **long-term hypertension control** or cardiovascular outcomes.

- **Exclusion Criteria Bias:** Patients who died before 90 days or lacked follow-up were excluded. These patients might represent a higher-risk group, potentially introducing **[[survivorship bias]]**.

- **Simplification Risks:** While score simplification (e.g., dichotomizing age or BP ranges) improves usability, it may reduce nuance in individual patient profiles.

The TRICH score has the potential to assist clinicians in initiating early **intensive antihypertensive therapy** in appropriate post-ICH patients, especially those with a high risk of needing triple therapy. However, caution is warranted to avoid overtreatment in those with transient BP elevation due to acute stress or underlying **[[cerebral amyloid angiopathy]]**.

The model performed better in patients with previously uncontrolled or untreated hypertension, reinforcing its value in guiding care where hypertension is known but uncontrolled. Lack of differentiation in patients with or without CAA suggests that further refinements or adjunct markers may be needed for this subgroup.

=== Future Directions ===  
- External validation in diverse populations, including **[[Caucasian]]**, **[[Africa]]n descent**, and **[[South Asia]]n** cohorts.

- Integration of biomarkers or imaging (e.g., **MRI markers of CAA**) to refine predictions.

- Evaluation of the TRICH score’s impact on **[[clinical outcome]]** when used in routine care.

=== Conclusion ===  
This well-conducted cohort study introduces a practical clinical tool—the TRICH score—for anticipating antihypertensive requirements after ICH. Despite its promise, broader validation and studies on downstream outcomes are essential before widespread implementation.