Although it has been established that elevated blood pressure and its variability worsen outcomes in spontaneous intracerebral hemorrhage, antihypertensives use during the acute phase still lacks robust evidence. A blood pressure–lowering regimen using remifentanil and dexmedetomidine might be a reasonable therapeutic option given their analgesic and antisympathetic effects. The objective of this superiority trial was to validate the efficacy and safety of this blood pressure–lowering strategy that uses remifentanil and dexmedetomidine in patients with acute intracerebral hemorrhage.
In this multicenter, prospective, single-blinded, superiority randomized controlled trial, patients with intracerebral hemorrhage and systolic blood pressure (SBP) 150 mmHg or greater were randomly allocated to the intervention group (a preset protocol with a standard guideline management using remifentanil and dexmedetomidine) or the control group (standard guideline-based management) to receive blood pressure–lowering treatment. The primary outcome was the SBP control rate (less than 140 mmHg) at 1 h posttreatment initiation. Secondary outcomes included blood pressure variability, neurologic function, and clinical outcomes.
A total of 338 patients were allocated to the intervention (n = 167) or control group (n = 171). The SBP control rate at 1 h posttreatment initiation in the intervention group was higher than that in controls (101 of 161, 62.7% vs. 66 of 166, 39.8%; difference, 23.2%; 95% CI, 12.4 to 34.1%; P < 0.001). Analysis of secondary outcomes indicated that patients in the intervention group could effectively reduce agitation while achieving lighter sedation, but no improvement in clinical outcomes was observed. Regarding safety, the incidence of bradycardia and respiratory depression was higher in the intervention group.
Among intracerebral hemorrhage patients with a SBP 150 mmHg or greater, a preset protocol using a remifentanil and dexmedetomidine–based standard guideline management significantly increased the SBP control rate at 1 h posttreatment compared with the standard guideline-based management.
- In patients who have suffered spontaneous intracerebral hemorrhage, excessively high blood pressure is associated with worse outcomes
- Existing blood pressure–lowering regimens involve administration of various antihypertensive drugs, but the optimal choice of treatment is unknown
- For this patient group, the use of dexmedetomidine and remifentanil results in a higher proportion of patients achieving good systolic blood pressure control at 1 h after admission than is seen in the control group
- Dexmedetomidine and remifentanil produced less agitation, but occasionally resulted in treatable bradycardia and respiratory depression
- There was no difference in hematoma growth and long-term stroke outcomes between the groups
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