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CHICAGO -- A registry study at four stroke centers suggested that keeping blood pressure (BP) variability down, instead of trying aggressively to lower BP, was the better option in patients with intracerebral hemorrhage.

Older age and female sex were two pre-hospital factors that were independently associated with high systolic BP variability after controlling for hemorrhage volume, pre-morbid modified Rankin Scale (mRS), and Glasgow Coma Scale scores, Jennifer Meeks, MS, of McGovern Medical School at UTHealth-Houston, reported here at the Joint Hypertension 2018 Scientific Sessions of the American Heart Association and the American Society of Hypertension.

In turn, high systolic BP variability was one of several predictors of 90-day disability and death:

• High systolic BP variability: adjusted RR 1.17 (95% CI 1.02-1.35)
• Age >80 years: adjusted RR 1.21 (95% CI 1.05-1.39)
• NIH Stroke Scale score >10: adjusted RR 1.56 (95% CI 1.28-1.85)
• Glasgow Coma Scale: scores 5-12 (adjusted RR 1.54, 95% CI 1.28-1.85) and 3-4 (adjusted RR 1.60, 95% CI 1.33-1.91)
• Premorbid mRS Score >1: adjusted RR 1.25 (95% CI 1.09-1.43)

This finding adds to the growing evidence that BP variability may drive poor outcomes. Meeks' study approached the issue differently from previous efforts, however, by including a broad range of patients of wide-ranging ICH severity, commented Craig Anderson, MD, PhD, of The George Institute for Global Health in Australia, in an interview.

Anderson was the principal investigator of the INTERACT-2 randomized trial that failed to show a reduction in 90-day death or disability with intensive BP lowering after ICH; it took a to show that, instead, it was systolic BP variability that was tied to worse outcomes.

For Meeks' study, the cut-off for high systolic BP variability was a standard deviation of 13.0 in each patient.

The retrospective analysis included 566 adults with radiologically-confirmed primary ICH who had over 120,500 systolic BP readings analyzed. Mean patient age was 63.5 and just over one-third were women. Median follow-up was 8.7 days.

The observational data precluded any causal findings and the study didn't account for oral antihypertensives given in-hospital or after discharge, Meeks acknowledged. Additionally, its generalizability is limited, given its reliance on certified stroke centers only (three primary stroke centers and one comprehensive stroke center).

If the findings are more broadly applicable, however, the future of ICH care would be controlling BP variability instead of taking a look at the absolute systolic BP value and decreasing it, Meeks suggested.

Said Anderson, "These data suggest that control of systolic BP involves not only reaching a suitable target (<140 mm Hg) as soon as possible upon presentation but also to ensure that their smooth control over the ensuring in-hospital care period."

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