A secondary analysis of the ATACH-2 trial (ClinicalTrials.gov Identifier: NCT01176565) published in Stroke shows that patients with intracerebral hemorrhage (ICH) and an increased systolic blood pressure variability (BPV) have worse long-term neurologic outcomes.

Study researchers monitored blood pressure readings for 0 to 2 hours following randomization in the ATACH-2 trial. Additionally, the investigators created an acute period and subacute period, defined as the 2 to 24 hours after randomization and days 2 to 7 of study enrollment, respectively. The researchers recorded highest and lowest systolic blood pressure every hour in the acute period as well as the 2 highest and lowest systolic blood pressure measurements every hour for days 2, 3, and 7 in the subacute phase.

The primary outcome was an unfavorable neurologic outcome, which was defined as a modified Rankin Scale (mRS) score of 3 to 6 at 3 months following randomization. Additionally, a utility-weighted mRS was used for the secondary outcome. The investigators also assessed whether changes in ICH volume, midline shift, and cerebral edema occurred.

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A total of 913 patients and 877 patients were included in the acute period and subacute period, respectively. The researchers observed a consistent relationship between increased BPV and worse neurologic outcome during the acute and subacute periods for 5 different statistical systolic BPV measures (eg, systolic standard deviation [SD], systolic coefficient of variation, systolic average real variability, systolic successive variation, and systolic residual standard deviation). BPV SD was significantly higher among patients who achieved the primary outcome in the acute period (15.1±5.8 vs 13.7±4.4 mmHg; P <.001) and subacute period (25.4±8.6 vs 21.1±7.8 mmHg; P <.001). Additionally, higher BPV was significantly associated with worse utility-weighted mRS in both the acute and subacute time periods (P <.001).

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The retrospective nature of the study and the ATACH-2 methodology of blood pressure assessment, which may have introduced bias, represent the main limitations of the analysis.

The researchers suggested that their study, “should prompt clinicians to consider monitoring BPV after ICH and reinforce the need for additional research into reducing BPV after stroke.”


de Havenon A, Majersik JJ, Stoddard G, et al. Increased blood pressure variability contributes to worse outcome after intracerebral hemorrhage: an analysis of ATACH-2 [published online July 16, 2018]. Stroke. doi: 10.1161/STROKEAHA.118.022133