Target Blood Pressure (BP):
IV Antihypertensives:
| Drug | Class | Notes |
|---|---|---|
| Labetalol | Ξ±/Ξ²-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 | Ξ²1-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)
BP Target:
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:
In a prospective cohort study with external validation study components, the authors used data from a longitudinal ICH registry (2011β2022) for score development and validated the model prospectively in three independent hospitals (2020β2022) 1)
The study aims to develop and validate a clinical score (the TRICH score) to predict the need for β₯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, Ξ²-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.
- 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.
- External validation in diverse populations, including Caucasian, African descent, and South Asian cohorts.
- Integration of biomarkers or imaging (e.g., MRI markers of CAA) to refine predictions.
- Evaluation of the TRICH scoreβs impact on clinical outcome when used in routine care.
This well-conducted cohort study introduces a practical clinical toolβthe TRICH scoreβfor anticipating antihypertensive requirements after ICH. Despite its promise, broader validation and studies on downstream outcomes are essential before widespread implementation.