Nationwide survey of antihypertensive treatment for acute intracerebral hemorrhage in Japan

Abstract

Acute hypertension is associated with hematoma enlargement and poor clinical outcomes in patients with intracerebral hemorrhage (ICH). However, the method of controlling blood pressure (BP) during the acute phase of ICH remains unknown. The aim of this study is to show current strategies about this issue in Japan. Questionnaires regarding antihypertensive treatment (AHT) strategies were sent to neurosurgeons, neurologists and others responsible for ICH management in 1424 hospitals. Of 600 respondents, 550 (92%) worked at hospitals wherein acute ICH patients are managed and 548 (99.6%) of them agreed with the application of AHT within 24 h of ICH onset. Most answered that the systolic BP threshold for starting AHT was 180 mm Hg (36%) or 160 mm Hg (31%), which differed significantly between neurosurgeons (median, 160 mm Hg) and neurologists/others (180 mm Hg, Po0.001). The goal of lowering systolic BP was to reach a maximum of 140, 150 or 160 mm Hg according to 448 respondents (82%) and 209 (38%) intensively lowered systolic BP to p140 mm Hg. Nicardipine was the first choice of intravenous drug for 313 (57%) and the second choice for 146 respondents (27%). However, 141 (26%) thought that nicardipine is inappropriate mainly because of a conflict with a description of contraindications on the official Japanese label for this drug. In conclusion, the present Japanese respondents, especially neurosurgeons, lower BP more aggressively than recommended in domestic and Western guidelines for managing acute ICH patients. Nicardipine was the most frequent choice of antihypertensive agent.

Systolic blood pressure lowering to 160 mmHg or less using nicardipine in acute intracerebral hemorrhage

“…The Japanese official label prohibited nicardipine use during hyperacute ICH [17]. In contrast, our nationwide survey on antihypertensive treatment strategies for ICH revealed inconsistencies with the recommendations [17]. The target SBP was 160 mmHg or less from 82% of Japanese respondents and 57% of respondents named intravenous nicardipine as the first choice antihypertensive drug.…”

“…The Japanese official label prohibited nicardipine use during hyperacute ICH [17]. In contrast, our nationwide survey on antihypertensive treatment strategies for ICH revealed inconsistencies with the recommendations [17].…”

“…Patients' background features were generally similar among the studies. Figure 2a shows the change in the NIHSS scores during the initial 72 h. The median NIHSS score was 13 (8)(9)(10)(11)(12)(13)(14)(15)(16)(17) at baseline and 10 (5-15) at 72 h (P < 0.0001). The average absolute change was À2 (À4 to 0).…”

Comparison of the European and Japanese Guidelines for the Acute Management of Intracerebral Hemorrhage

“…nicardipine) is contraindicated in patients with hyperacute ICH, because of vasodilating effects and possible antiplatelet actions of calcium antagonists; however, direct evidence for this is lacking. In the above-mentioned nationwide survey, nicardipine was the most popular agent for acute ICH management [7]. In 2011, the Japanese government finally ordered the pharmaceutical makers of nicardipine to revise the label.…”

“…Further clinical studies need to be conducted in the future to determine the optimal target level to which blood pressure should be lowered from the perspective of clinical prognosis. The target level in the Japanese guidelines is quite high (systolic blood pressure <180 mm Hg) and differs much from the major expert opinions in the nationwide survey [7], where most experts regarded <140, <150 or <160 mm Hg as a target systolic blood pressure partly based on results of small domestic studies [8,9]. The EUSI guidelines recommend target levels and maximum levels of blood pressure for known and unknown hypertension, and recommend an adaptation in case of elevated intracranial pressure (ICP).…”