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evident
Original paper
2016NEJMNeurology

ATACH-2

Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage

RCTIntracerebral hemorrhage

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Overview

Targeting SBP 110 to 139 mm Hg in acute ICH did not reduce death or disability versus 140 to 179 mm Hg and increased renal adverse events.

Clinical takeaway

Pushing SBP into the 110 to 139 mm Hg range after ICH did not improve death or disability and caused more renal adverse events.

Key result

Death or disability (mRS 4-6) at 3 months was 38.7% with intensive treatment vs 37.7% with standard treatment (adjusted RR 1.04; 95% CI 0.85-1.27).

Practice impact

Do not push SBP into the 110 to 139 mm Hg range after ICH; a 140 to 179 mm Hg target was not worse and caused fewer renal events.

Evidence

Study design

Randomized trial testing intensive versus standard systolic blood-pressure reduction with intravenous nicardipine.

Enrollment

1,000

Follow-up

Death or disability assessed at 3 months.

Geography

Not listed

Clinical question

Does lowering systolic blood pressure to 110 to 139 mm Hg reduce death or disability after acute intracerebral hemorrhage compared with a target of 140 to 179 mm Hg?

Population

  • Patients with intracerebral hemorrhage volume less than 60 cm3 and a Glasgow Coma Scale score of 5 or more, treated within 4.5 hours after symptom onset.

Intervention

Intensive systolic blood-pressure target of 110 to 139 mm Hg using intravenous nicardipine.

Comparator

Standard systolic blood-pressure target of 140 to 179 mm Hg.

Primary outcome

Death or disability, defined as a modified Rankin scale score of 4 to 6 at 3 months.

An intensive systolic target of 110 to 139 mm Hg did not reduce death or disability compared with a target of 140 to 179 mm Hg.

Adjusted relative risk / 1.04 / 95% CI 0.85-1.27

Key results

  • The primary outcome occurred in 38.7% with intensive treatment vs 37.7% with standard treatment (RR 1.04; 95% CI 0.85-1.27), adjusted for age, initial GCS, and intraventricular hemorrhage.
  • Enrollment stopped for futility after a prespecified interim analysis.
  • Mean baseline systolic blood pressure was 200.6 mm Hg; 56.2% of participants were Asian.

Harms

  • Treatment-related serious adverse events within 72 hours occurred in 1.6% with intensive treatment and 1.2% with standard treatment.
  • Renal adverse events within 7 days were more common with intensive treatment (9.0% vs 4.0%; p=0.002).

Clinical Use

Practice impact

  • Do not push SBP into the 110 to 139 mm Hg range after ICH; a 140 to 179 mm Hg target was not worse and caused fewer renal events.

Applicability

  • Most applicable to ICH under 60 cm3 with GCS of 5 or more when intravenous nicardipine can be started within 4.5 hours.

Limitations

  • The trial stopped for futility, so it does not define a benefit of intensive lowering.
  • The intensive target of 110 to 139 mm Hg is lower than INTERACT2's goal below 140 mm Hg.
  • The primary disability cut was modified Rankin 4-6, not 3-6.

Common misinterpretations

  • ATACH-2 does not say blood-pressure treatment is unnecessary; it says a 110 to 139 target is not better than 140 to 179.
  • Similar early treatment-related serious events do not erase the renal-harm signal.

Related evidence

INTERACT2 - Earlier TrialPATCH - Same Disease

Citation

Qureshi AI, Palesch YY, Barsan WG, et al. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. N Engl J Med. 2016;375(11):1033-1043. doi:10.1056/NEJMoa1603460

The treatment of participants with intracerebral hemorrhage to achieve a target systolic blood pressure of 110 to 139 mm Hg did not result in a lower rate of death or disability than standard reduction to a target of 140 to 179 mm Hg.