INTERACT 2 TRIAL
The INTERACT 2 trial involved 2800 patients from 140 centers worldwide to determine if early intensive lowering of blood pressure in patients with intracerebral hemorrhage is safe and effective. Patients within 6 hours of onset with systolic BP 150-220 mmHg were randomized to either intensive BP treatment targeting <140 mmHg or standard guideline-based management targeting <180 mmHg. The primary outcome was death or major disability at 90 days. Results showed intensive treatment lowered systolic BP significantly more at 1 and 6 hours but did not significantly reduce the primary outcome compared to standard treatment.
This study aimed to determine if rapidly lowering systolic blood pressure to 110-139 mmHg improves outcomes for patients with intracerebral hemorrhage, compared to standard treatment lowering it to 140-179 mmHg. Over 8500 patients were screened and 1000 were randomized to aggressive or standard treatment groups. There was no significant difference in the primary outcome of death or disability at 90 days between groups. The study suggests that intensive blood pressure reduction does not improve outcomes for intracerebral hemorrhage patients.
This document summarizes several studies on the relationship between blood pressure (BP) and outcomes in patients with intracerebral hemorrhage (ICH). The studies found that:
1) Higher systolic BP variability during the initial 24 hours of ICH was associated with worse neurological outcomes and mortality. Stable BP control may improve prognosis.
2) Higher systolic BP loads (proportion of readings above 180 mmHg) within 24 hours independently predicted hematoma expansion and neurological deterioration.
3) Lower achieved systolic BP levels (median of 135 mmHg) within 24 hours through intensive BP reduction were associated with less hematoma growth compared to higher BP levels.
This study aimed to determine if early antihypertensive therapy in patients with acute ischemic stroke leads to different outcomes in those with and without a history of hypertension. Over 4 years, 4,071 patients were randomly assigned to either strict blood pressure control or usual care. Strict control led to greater reductions in blood pressure over 24 hours, 7 days and 14 days, with no differences in short-term death or disability regardless of hypertension history. However, early blood pressure reduction was associated with a lower rate of recurrent stroke in patients with a history of hypertension.
The document discusses updates on stroke prevention and management. It summarizes recent findings related to primary stroke prevention involving homocysteine, folic acid, and B vitamins. It also discusses definitions and management of transient ischemic attacks, as well as treatments for acute ischemic stroke such as thrombolysis. Finally, it reviews options for secondary stroke prevention based on the underlying causes, emphasizing the use of antiplatelet agents for most etiologies according to American Stroke Association guidelines. The summary is provided in 3 sentences or less as requested.
Hypertension clinical management of primary hypertension in adultsLAB IDEA
This document provides guidelines for the clinical management of primary hypertension in adults. It partially updates and replaces previous NICE guidance from 2006. The guidelines cover measuring and diagnosing hypertension, assessing cardiovascular risk and organ damage, lifestyle interventions, initiating and monitoring drug treatment including blood pressure targets, choosing antihypertensive drugs, and patient education and adherence. It aims to help healthcare professionals provide high-quality care for adults with primary hypertension.
1) The JATOS trial found no difference in outcomes between a target BP of <150/90 mmHg vs <140/90 mmHg in patients aged 65-85 years.
2) The VALISH trial found no difference in outcomes between a target BP of <150/90 mmHg vs <140/90 mmHg in patients aged 70-84 years with isolated systolic hypertension treated with valsartan.
3) The AASK trial found intensive BP control (<130/80 mmHg) did not slow kidney disease progression overall but may be protective in those with significant proteinuria.
This document discusses guidelines and considerations for clinical trials in hypertension. It provides information on:
1. The increasing global prevalence and costs of hypertension, with an estimated 1.6 billion hypertensive patients by 2025.
2. Guidelines for classifying and treating hypertension from organizations like JNC, WHO, and ESC/ESH. The JNC 8 guideline is evidence-based and recommends treatment thresholds, goals, and medications based on randomized controlled trials.
3. Methodological considerations for designing and conducting clinical trials to evaluate antihypertensive drugs and combinations, including study populations, measures of efficacy like blood pressure and target organ damage, safety aspects, and trial durations. Long-term safety data is important
Effect of hydrocortisone on development of shock amongDr fakhir Raza
effects of hydrocortisone on development of shock among patients with severe sepsis the HYPRESS Randomized Clinical Trial American Medical Association caring for the critically ill patients Surviving sepsis campaign, to determine weather hydrocortisone therapy in patients with severe sepsis prevents the development of septic shock
This study aimed to determine if rapidly lowering systolic blood pressure to 110-139 mmHg improves outcomes for patients with intracerebral hemorrhage, compared to standard treatment lowering it to 140-179 mmHg. Over 8500 patients were screened and 1000 were randomized to aggressive or standard treatment groups. There was no significant difference in the primary outcome of death or disability at 90 days between groups. The study suggests that intensive blood pressure reduction does not improve outcomes for intracerebral hemorrhage patients.
This document summarizes several studies on the relationship between blood pressure (BP) and outcomes in patients with intracerebral hemorrhage (ICH). The studies found that:
1) Higher systolic BP variability during the initial 24 hours of ICH was associated with worse neurological outcomes and mortality. Stable BP control may improve prognosis.
2) Higher systolic BP loads (proportion of readings above 180 mmHg) within 24 hours independently predicted hematoma expansion and neurological deterioration.
3) Lower achieved systolic BP levels (median of 135 mmHg) within 24 hours through intensive BP reduction were associated with less hematoma growth compared to higher BP levels.
This study aimed to determine if early antihypertensive therapy in patients with acute ischemic stroke leads to different outcomes in those with and without a history of hypertension. Over 4 years, 4,071 patients were randomly assigned to either strict blood pressure control or usual care. Strict control led to greater reductions in blood pressure over 24 hours, 7 days and 14 days, with no differences in short-term death or disability regardless of hypertension history. However, early blood pressure reduction was associated with a lower rate of recurrent stroke in patients with a history of hypertension.
The document discusses updates on stroke prevention and management. It summarizes recent findings related to primary stroke prevention involving homocysteine, folic acid, and B vitamins. It also discusses definitions and management of transient ischemic attacks, as well as treatments for acute ischemic stroke such as thrombolysis. Finally, it reviews options for secondary stroke prevention based on the underlying causes, emphasizing the use of antiplatelet agents for most etiologies according to American Stroke Association guidelines. The summary is provided in 3 sentences or less as requested.
Hypertension clinical management of primary hypertension in adultsLAB IDEA
This document provides guidelines for the clinical management of primary hypertension in adults. It partially updates and replaces previous NICE guidance from 2006. The guidelines cover measuring and diagnosing hypertension, assessing cardiovascular risk and organ damage, lifestyle interventions, initiating and monitoring drug treatment including blood pressure targets, choosing antihypertensive drugs, and patient education and adherence. It aims to help healthcare professionals provide high-quality care for adults with primary hypertension.
1) The JATOS trial found no difference in outcomes between a target BP of <150/90 mmHg vs <140/90 mmHg in patients aged 65-85 years.
2) The VALISH trial found no difference in outcomes between a target BP of <150/90 mmHg vs <140/90 mmHg in patients aged 70-84 years with isolated systolic hypertension treated with valsartan.
3) The AASK trial found intensive BP control (<130/80 mmHg) did not slow kidney disease progression overall but may be protective in those with significant proteinuria.
This document discusses guidelines and considerations for clinical trials in hypertension. It provides information on:
1. The increasing global prevalence and costs of hypertension, with an estimated 1.6 billion hypertensive patients by 2025.
2. Guidelines for classifying and treating hypertension from organizations like JNC, WHO, and ESC/ESH. The JNC 8 guideline is evidence-based and recommends treatment thresholds, goals, and medications based on randomized controlled trials.
3. Methodological considerations for designing and conducting clinical trials to evaluate antihypertensive drugs and combinations, including study populations, measures of efficacy like blood pressure and target organ damage, safety aspects, and trial durations. Long-term safety data is important
Effect of hydrocortisone on development of shock amongDr fakhir Raza
effects of hydrocortisone on development of shock among patients with severe sepsis the HYPRESS Randomized Clinical Trial American Medical Association caring for the critically ill patients Surviving sepsis campaign, to determine weather hydrocortisone therapy in patients with severe sepsis prevents the development of septic shock
This document summarizes a journal club discussion of a randomized trial comparing outcomes of intracranial pressure monitoring versus clinical examination alone for patients with severe traumatic brain injury. Key points included that the trial found similar outcomes between the two groups in composite endpoints and mortality. However, the intracranial pressure monitoring group received more aggressive treatments such as barbiturates. There was skepticism around applying the results to clinical practice in the US due to differences in pre-hospital care, rehabilitation standards, and treatment protocols between the study locations and the US.
Practice of Indian Physicians Towards Use of Calcium Channel Blockers in the ...Mahdy Ali Ahmad Osman
A journal club on the Practice of Indian Physicians Towards Use of Calcium Channel Blockers in the Management of
Hypertension A Paper Based Questionnaire Survey, research.
The SPRINT trial tested whether treating systolic blood pressure to a lower goal of <120 mm Hg compared to <140 mm Hg would reduce cardiovascular events. Interim results found the intensive treatment reduced cardiovascular complications by 30% and mortality by 25%, leading the trial to stop early. Final results are forthcoming to determine effects on other outcomes like dementia and kidney function.
The Systolic Blood Pressure Intervention Trial (SPRINT) aims to test whether treating high blood pressure to a goal of lower than 120 mm Hg can reduce cardiovascular risks more than the current recommended goal of lower than 140 mm Hg. SPRINT will randomize over 9,000 patients at risk of heart disease to either an intensive treatment group aiming for systolic blood pressure under 120 mm Hg or a standard group under 140 mm Hg. The primary outcome is a composite of heart attack, stroke, heart failure, and cardiovascular death. SPRINT will provide evidence on the feasibility and risks/benefits of this more intensive blood pressure control strategy.
- The POINT trial investigated whether clopidogrel plus aspirin reduces new ischemic vascular events compared to placebo plus aspirin in patients with minor stroke or high-risk TIA treated within 12 hours.
- Over 4,800 patients from 269 sites in 10 countries were randomly assigned to clopidogrel+aspirin or placebo+aspirin. Patients receiving clopidogrel had a 25% lower risk of stroke or other ischemic events but a higher risk of major bleeding.
- The trial was stopped early due to a safety signal of increased major hemorrhage in the clopidogrel group. However, clopidogrel was found to provide benefit for ischemic outcomes within the first 3 weeks
complications of thrombolysis (alteplase) in strokeNeurologyKota
This document summarizes key information about the use of recombinant tissue plasminogen activator (r-tPA, also known as alteplase) for the treatment of acute ischemic stroke (AIS). It discusses FDA approval of r-tPA for AIS, dosing and administration, mechanisms of action, risks and rates of symptomatic intracerebral hemorrhage, eligibility criteria, monitoring parameters, contraindications, and management of hemorrhagic complications.
The SPRINT trial studied over 9,000 patients at high risk for cardiovascular events to compare intensive blood pressure control (target <120 mm Hg systolic) to standard control (target <140 mm Hg). It found that intensive control significantly reduced rates of fatal and nonfatal heart attacks, heart failure, and death from any cause. However, intensive control also increased some adverse effects like acute kidney injury and hypotension. Overall, the trial demonstrated benefits of very tight blood pressure control for high-risk patients without diabetes.
The document summarizes the SPRINT trial which compared intensive blood pressure control (target SBP <120 mm Hg) to standard treatment (target SBP 135-139 mm Hg) in patients at high risk for cardiovascular disease but without diabetes or history of stroke. The trial found that intensive treatment reduced the occurrence of heart attacks, heart failure, and death by about 25% compared to standard treatment. However, intensive treatment also increased the risk of acute kidney injury, particularly in those without chronic kidney disease at baseline. Overall, the trial demonstrated that intensive blood pressure control provides significant cardiovascular benefits for high-risk patients.
Recent Advances In Thrombolysis In Stroke PatientAdamya Gupta
1) Recent advances in thrombolysis for stroke patients include extending the treatment window for intravenous rt-PA from 3 hours to 4.5 hours post-stroke onset based on the ECASS III trial results.
2) Intravenous rt-PA is still the standard of care for eligible patients within 4.5 hours, but endovascular thrombectomy is now recommended for eligible patients with a large vessel occlusion up to 24 hours from last known normal.
3) Treatment protocols now focus on a rapid door-to-needle time of 60 minutes or less for intravenous rt-PA and include advances in imaging such as CTA and perfusion imaging to identify patients that may benefit from endovascular thrombectomy.
This document summarizes evidence from multiple clinical trials evaluating the use of thrombolysis/tissue plasminogen activator (tPA) for acute ischemic stroke. It discusses trials showing small benefits for functional outcomes with tPA if given within 3 hours, as well as increased risks of intracranial hemorrhage. Later trials found no clear benefits for tPA between 3-6 hours. Overall, tPA for acute stroke provides only modest benefits for a small proportion of patients, but is also associated with significant risks.
Tenecteplase X Alteplase no Acidente Vascular Cerebral - AVCJeferson Espindola
This randomized controlled trial compared the thrombolytic drugs tenecteplase and alteplase for the treatment of acute ischemic stroke. The trial assigned 75 patients in a 1:1:1 ratio to receive either alteplase (the standard treatment), tenecteplase at a dose of 0.1 mg/kg, or tenecteplase at a higher dose of 0.25 mg/kg. Patients were selected based on having a large perfusion lesion on CT imaging and an associated vessel occlusion. The primary outcomes were the extent of reperfusion on MRI and clinical improvement at 24 hours. The results showed that the tenecteplase groups had significantly greater reperfusion and clinical improvement compared to al
1) The SPRINT trial was a randomized controlled trial that compared an intensive blood pressure treatment target of less than 120 mmHg to a standard target of less than 140 mmHg. 9,361 participants aged 50 and older with high cardiovascular risk were enrolled and followed for a median of 3.26 years.
2) The primary outcome was a composite of myocardial infarction, other acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes. Key secondary outcomes included all-cause mortality and renal outcomes.
3) Results found that the intensive treatment target reduced the primary composite outcome by 25% and all-cause mortality by 27%, showing benefit of the lower blood pressure target. The trial was stopped early due
Every anesthesiologist worth their salt is guilty of administering a wrong drug at least once in their career. Most of the time the consequences have been harmless (albeit not without feeling of guilt or remorse), but in some cases they have caused an undesired iatrogenic morbidity and/or mortality. The high duress milieu of an operation theater (OT), intensive care unit (ICU) or emergency room (ER) predisposes flawed actions. Pediatric population in OT, ICU, or ER is at considerable hazard for medication blunders. Once injected into the blood stream, a drug cannot be retrieved, only countered. A time for change in the field of anesthesiology is inevitable. As indicated previously, medical errors are prevalent within this field and current safety protocol has not been changed in over 60 years. Not only will the implementation of a device like VEINROM increase practitioner's accountability, update patient records in real time and improve the overall health care system, it will most importantly save lives. It is an obligation for standards committee members and medical device manufacturers to implement safeguards that prevent human error. The Institute of medicine estimates that at least 1.5 million Americans are injured each year as a result of EDA, costing the US healthcare field more than 3.5 billion USD annually. The global health care system is in the process of implementing improved standards and regulations that require syringes to be pre-filled by outside pharmacies rather than medical practitioners during the pre-operation period. To support this claim, Transparency Market Research estimates that the global pre-filled syringe market will grow by a 13.3% compound annual rate, reaching a market value of 4.98 billion USD by the year 2019 . These trends point to an estimated 3 billion USD in profit opportunity within the next 7 years.
It is our moral and Hippocratic duty to continue risk management processes that decrease the probability of iatrogenic morbidities. For a device such as VEINROM, the time is right and future, bright. Medical device innovation is continuous and safety measures are continually updated. VEINROM is the next step in making the art of anesthesia safer for all involved.
Remote Ischaemic Conditioning: A Paper Review & Uses in Paramedic Practicebgander23
A 2 part presentation. Part 1 reviews a paper on the long-term clinical outcomes of STEMI patients undergoing remote ischaemic perconditioning prior to primary percutaneous coronary intervention. The 2nd part looks at how this technique can be used in Paramedic practice.
Health Policy - Use of IV tPA for Acute Ischemic StrokesZach Jarou
Stroke is a leading cause of death and disability in the US. Treatment with the drug tPA within 3 hours of stroke onset can reverse deficits, but it is underutilized due to its risk of hemorrhage and narrow treatment window. The document argues that public education on stroke symptoms and increasing the treatment window to 4.5 hours based on evidence from trials could increase tPA use and reduce disability, but its risks still require careful patient selection.
Ticagrelor and Aspirin or Aspirin alone in Acute Ischmic Stroke or TIA(THALES...Diptiman Behera
This document summarizes the results of the THALES clinical trial which compared ticagrelor plus aspirin to aspirin alone for preventing stroke in patients with minor acute ischemic stroke or high-risk transient ischemic attack (TIA). The trial found that ticagrelor plus aspirin reduced the risk of the primary outcome of stroke or death compared to aspirin alone, with rates of 5.5% vs 6.6% respectively. Rates of the secondary outcome of subsequent ischemic stroke were also lower in the ticagrelor group. Rates of disability did not differ between groups. Severe bleeding was higher with ticagrelor but intracranial hemorrhage was similar between groups. The study demonstrates
1) Intravenous thrombolysis (IVT) with alteplase remains the standard treatment for acute ischemic stroke within 4.5 hours of symptom onset. Pivotal clinical trials in 1995 and 2008 demonstrated that IVT can reduce disability and is safe, with about a 7% risk of symptomatic intracranial hemorrhage.
2) Real-world data from registries show that IVT results in functional independence for 40-45% of patients at 3 months, and is effective in patients over 80 years old. Faster treatment times are associated with better outcomes.
3) Current research aims to increase the number of patients treated by overcoming some contraindications to IVT, and to
This study analyzed 130 helicopter rescue missions in Australia that involved winching a physician to the scene. It found that 40% of patients received physician-only interventions (POIs) such as advanced analgesia/sedation, airway management, circulatory support, and orthopaedic manipulation. Patients with abnormal vital signs were more likely to receive a POI. Undertaking a POI did not impact scene time. The high POI rate and sometimes severe injuries support including physicians in winch rescues to provide time-critical interventions and advanced care.
This document summarizes the results of the ENCHANTED clinical trial which compared low-dose (0.6 mg/kg) intravenous alteplase to standard-dose (0.9 mg/kg) for acute ischemic stroke. The trial found that low-dose alteplase was not inferior to standard-dose for functional outcomes at 90 days, carried a lower risk of symptomatic intracerebral hemorrhage, and showed a trend toward lower mortality. Specifically, major hemorrhage occurred in 1.0% of low-dose patients versus 2.1% of standard-dose patients. Mortality was also lower in the low-dose group at 7 days. The study demonstrates that a lower dose of
This document summarizes a journal club discussion of a randomized trial comparing outcomes of intracranial pressure monitoring versus clinical examination alone for patients with severe traumatic brain injury. Key points included that the trial found similar outcomes between the two groups in composite endpoints and mortality. However, the intracranial pressure monitoring group received more aggressive treatments such as barbiturates. There was skepticism around applying the results to clinical practice in the US due to differences in pre-hospital care, rehabilitation standards, and treatment protocols between the study locations and the US.
Practice of Indian Physicians Towards Use of Calcium Channel Blockers in the ...Mahdy Ali Ahmad Osman
A journal club on the Practice of Indian Physicians Towards Use of Calcium Channel Blockers in the Management of
Hypertension A Paper Based Questionnaire Survey, research.
The SPRINT trial tested whether treating systolic blood pressure to a lower goal of <120 mm Hg compared to <140 mm Hg would reduce cardiovascular events. Interim results found the intensive treatment reduced cardiovascular complications by 30% and mortality by 25%, leading the trial to stop early. Final results are forthcoming to determine effects on other outcomes like dementia and kidney function.
The Systolic Blood Pressure Intervention Trial (SPRINT) aims to test whether treating high blood pressure to a goal of lower than 120 mm Hg can reduce cardiovascular risks more than the current recommended goal of lower than 140 mm Hg. SPRINT will randomize over 9,000 patients at risk of heart disease to either an intensive treatment group aiming for systolic blood pressure under 120 mm Hg or a standard group under 140 mm Hg. The primary outcome is a composite of heart attack, stroke, heart failure, and cardiovascular death. SPRINT will provide evidence on the feasibility and risks/benefits of this more intensive blood pressure control strategy.
- The POINT trial investigated whether clopidogrel plus aspirin reduces new ischemic vascular events compared to placebo plus aspirin in patients with minor stroke or high-risk TIA treated within 12 hours.
- Over 4,800 patients from 269 sites in 10 countries were randomly assigned to clopidogrel+aspirin or placebo+aspirin. Patients receiving clopidogrel had a 25% lower risk of stroke or other ischemic events but a higher risk of major bleeding.
- The trial was stopped early due to a safety signal of increased major hemorrhage in the clopidogrel group. However, clopidogrel was found to provide benefit for ischemic outcomes within the first 3 weeks
complications of thrombolysis (alteplase) in strokeNeurologyKota
This document summarizes key information about the use of recombinant tissue plasminogen activator (r-tPA, also known as alteplase) for the treatment of acute ischemic stroke (AIS). It discusses FDA approval of r-tPA for AIS, dosing and administration, mechanisms of action, risks and rates of symptomatic intracerebral hemorrhage, eligibility criteria, monitoring parameters, contraindications, and management of hemorrhagic complications.
The SPRINT trial studied over 9,000 patients at high risk for cardiovascular events to compare intensive blood pressure control (target <120 mm Hg systolic) to standard control (target <140 mm Hg). It found that intensive control significantly reduced rates of fatal and nonfatal heart attacks, heart failure, and death from any cause. However, intensive control also increased some adverse effects like acute kidney injury and hypotension. Overall, the trial demonstrated benefits of very tight blood pressure control for high-risk patients without diabetes.
The document summarizes the SPRINT trial which compared intensive blood pressure control (target SBP <120 mm Hg) to standard treatment (target SBP 135-139 mm Hg) in patients at high risk for cardiovascular disease but without diabetes or history of stroke. The trial found that intensive treatment reduced the occurrence of heart attacks, heart failure, and death by about 25% compared to standard treatment. However, intensive treatment also increased the risk of acute kidney injury, particularly in those without chronic kidney disease at baseline. Overall, the trial demonstrated that intensive blood pressure control provides significant cardiovascular benefits for high-risk patients.
Recent Advances In Thrombolysis In Stroke PatientAdamya Gupta
1) Recent advances in thrombolysis for stroke patients include extending the treatment window for intravenous rt-PA from 3 hours to 4.5 hours post-stroke onset based on the ECASS III trial results.
2) Intravenous rt-PA is still the standard of care for eligible patients within 4.5 hours, but endovascular thrombectomy is now recommended for eligible patients with a large vessel occlusion up to 24 hours from last known normal.
3) Treatment protocols now focus on a rapid door-to-needle time of 60 minutes or less for intravenous rt-PA and include advances in imaging such as CTA and perfusion imaging to identify patients that may benefit from endovascular thrombectomy.
This document summarizes evidence from multiple clinical trials evaluating the use of thrombolysis/tissue plasminogen activator (tPA) for acute ischemic stroke. It discusses trials showing small benefits for functional outcomes with tPA if given within 3 hours, as well as increased risks of intracranial hemorrhage. Later trials found no clear benefits for tPA between 3-6 hours. Overall, tPA for acute stroke provides only modest benefits for a small proportion of patients, but is also associated with significant risks.
Tenecteplase X Alteplase no Acidente Vascular Cerebral - AVCJeferson Espindola
This randomized controlled trial compared the thrombolytic drugs tenecteplase and alteplase for the treatment of acute ischemic stroke. The trial assigned 75 patients in a 1:1:1 ratio to receive either alteplase (the standard treatment), tenecteplase at a dose of 0.1 mg/kg, or tenecteplase at a higher dose of 0.25 mg/kg. Patients were selected based on having a large perfusion lesion on CT imaging and an associated vessel occlusion. The primary outcomes were the extent of reperfusion on MRI and clinical improvement at 24 hours. The results showed that the tenecteplase groups had significantly greater reperfusion and clinical improvement compared to al
1) The SPRINT trial was a randomized controlled trial that compared an intensive blood pressure treatment target of less than 120 mmHg to a standard target of less than 140 mmHg. 9,361 participants aged 50 and older with high cardiovascular risk were enrolled and followed for a median of 3.26 years.
2) The primary outcome was a composite of myocardial infarction, other acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes. Key secondary outcomes included all-cause mortality and renal outcomes.
3) Results found that the intensive treatment target reduced the primary composite outcome by 25% and all-cause mortality by 27%, showing benefit of the lower blood pressure target. The trial was stopped early due
Every anesthesiologist worth their salt is guilty of administering a wrong drug at least once in their career. Most of the time the consequences have been harmless (albeit not without feeling of guilt or remorse), but in some cases they have caused an undesired iatrogenic morbidity and/or mortality. The high duress milieu of an operation theater (OT), intensive care unit (ICU) or emergency room (ER) predisposes flawed actions. Pediatric population in OT, ICU, or ER is at considerable hazard for medication blunders. Once injected into the blood stream, a drug cannot be retrieved, only countered. A time for change in the field of anesthesiology is inevitable. As indicated previously, medical errors are prevalent within this field and current safety protocol has not been changed in over 60 years. Not only will the implementation of a device like VEINROM increase practitioner's accountability, update patient records in real time and improve the overall health care system, it will most importantly save lives. It is an obligation for standards committee members and medical device manufacturers to implement safeguards that prevent human error. The Institute of medicine estimates that at least 1.5 million Americans are injured each year as a result of EDA, costing the US healthcare field more than 3.5 billion USD annually. The global health care system is in the process of implementing improved standards and regulations that require syringes to be pre-filled by outside pharmacies rather than medical practitioners during the pre-operation period. To support this claim, Transparency Market Research estimates that the global pre-filled syringe market will grow by a 13.3% compound annual rate, reaching a market value of 4.98 billion USD by the year 2019 . These trends point to an estimated 3 billion USD in profit opportunity within the next 7 years.
It is our moral and Hippocratic duty to continue risk management processes that decrease the probability of iatrogenic morbidities. For a device such as VEINROM, the time is right and future, bright. Medical device innovation is continuous and safety measures are continually updated. VEINROM is the next step in making the art of anesthesia safer for all involved.
Remote Ischaemic Conditioning: A Paper Review & Uses in Paramedic Practicebgander23
A 2 part presentation. Part 1 reviews a paper on the long-term clinical outcomes of STEMI patients undergoing remote ischaemic perconditioning prior to primary percutaneous coronary intervention. The 2nd part looks at how this technique can be used in Paramedic practice.
Health Policy - Use of IV tPA for Acute Ischemic StrokesZach Jarou
Stroke is a leading cause of death and disability in the US. Treatment with the drug tPA within 3 hours of stroke onset can reverse deficits, but it is underutilized due to its risk of hemorrhage and narrow treatment window. The document argues that public education on stroke symptoms and increasing the treatment window to 4.5 hours based on evidence from trials could increase tPA use and reduce disability, but its risks still require careful patient selection.
Ticagrelor and Aspirin or Aspirin alone in Acute Ischmic Stroke or TIA(THALES...Diptiman Behera
This document summarizes the results of the THALES clinical trial which compared ticagrelor plus aspirin to aspirin alone for preventing stroke in patients with minor acute ischemic stroke or high-risk transient ischemic attack (TIA). The trial found that ticagrelor plus aspirin reduced the risk of the primary outcome of stroke or death compared to aspirin alone, with rates of 5.5% vs 6.6% respectively. Rates of the secondary outcome of subsequent ischemic stroke were also lower in the ticagrelor group. Rates of disability did not differ between groups. Severe bleeding was higher with ticagrelor but intracranial hemorrhage was similar between groups. The study demonstrates
1) Intravenous thrombolysis (IVT) with alteplase remains the standard treatment for acute ischemic stroke within 4.5 hours of symptom onset. Pivotal clinical trials in 1995 and 2008 demonstrated that IVT can reduce disability and is safe, with about a 7% risk of symptomatic intracranial hemorrhage.
2) Real-world data from registries show that IVT results in functional independence for 40-45% of patients at 3 months, and is effective in patients over 80 years old. Faster treatment times are associated with better outcomes.
3) Current research aims to increase the number of patients treated by overcoming some contraindications to IVT, and to
This study analyzed 130 helicopter rescue missions in Australia that involved winching a physician to the scene. It found that 40% of patients received physician-only interventions (POIs) such as advanced analgesia/sedation, airway management, circulatory support, and orthopaedic manipulation. Patients with abnormal vital signs were more likely to receive a POI. Undertaking a POI did not impact scene time. The high POI rate and sometimes severe injuries support including physicians in winch rescues to provide time-critical interventions and advanced care.
This document summarizes the results of the ENCHANTED clinical trial which compared low-dose (0.6 mg/kg) intravenous alteplase to standard-dose (0.9 mg/kg) for acute ischemic stroke. The trial found that low-dose alteplase was not inferior to standard-dose for functional outcomes at 90 days, carried a lower risk of symptomatic intracerebral hemorrhage, and showed a trend toward lower mortality. Specifically, major hemorrhage occurred in 1.0% of low-dose patients versus 2.1% of standard-dose patients. Mortality was also lower in the low-dose group at 7 days. The study demonstrates that a lower dose of
This document summarizes the INTERACT2 trial which studied the effects of early intensive blood pressure lowering in patients with intracerebral hemorrhage. The trial involved over 2800 patients across 21 countries who were randomized to either receive intensive treatment to lower their blood pressure below 140 mmHg within 1 hour or guideline-recommended treatment with no lower target. The primary outcome was death or major disability at 90 days. While intensive treatment did not significantly reduce the primary outcome, ordinal analysis showed better functional outcomes. Intensive treatment also improved quality of life scores and was not associated with higher death or adverse event rates.
This document summarizes the results of several clinical trials evaluating renal denervation for the treatment of hypertension. The SYMPLICITY HTN-3 trial, the largest study to date, found no significant difference in blood pressure reduction between the renal denervation and sham procedure groups. Subgroup analyses found some predictors of greater blood pressure response, such as use of alpha-1 blockers or baseline blood pressure over 180 mmHg. Overall, the data from clinical trials on renal denervation is mixed, with early studies showing promising results but larger trials like SYMPLICITY HTN-3 finding no clear benefit over sham procedures.
This randomized controlled trial compared the efficacy of enoxaparin versus placebo for preventing symptomatic venous thromboembolism in 2559 hospitalized older adult medical patients. The primary outcome of symptomatic deep vein thrombosis, pulmonary embolism or fatal pulmonary embolism within 30 days occurred in 1.8% of patients receiving enoxaparin and 2.2% of patients receiving placebo, showing no significant difference. Secondary outcomes including events up to 90 days also showed no significant differences in efficacy or safety between the groups. The results do not support the routine use of enoxaparin for thromboprophylaxis in this population.
This document summarizes the Antihypertensive Treatment of Acute Cerebral Hemorrhage II (ATACH-2) trial, which aimed to determine if rapidly lowering systolic blood pressure to ≤140 mm Hg (intensive treatment) versus ≤180 mm Hg (standard treatment) in patients with intracerebral hemorrhage treated within 4.5 hours of symptom onset reduces death and disability. The trial randomized patients to 24 hours of intravenous nicardipine to achieve the assigned blood pressure target. The primary outcome was death or disability (modified Rankin score 4-6) at 3 months. Secondary outcomes included hematoma expansion and quality of life measures.
This document provides an overview of the management of hypertensive intracerebral bleed (ICH). Key points include:
1) Uncontrolled hypertension is the leading risk factor for ICH. Early diagnosis with non-contrast CT is important for appropriate care and outcomes.
2) Acute management focuses on preventing hematoma expansion through aggressive blood pressure control to SBP 140 mmHg, reversing anticoagulants, and considering platelet transfusion.
3) Other priorities are treating increased intracranial pressure through measures like head elevation, osmotic therapies, and CSF drainage if hydrocephalus is present. Salvage therapies like induced coma and neuromuscular blockade are reserved for refract
Hot Topics in Critical Care - March 2017Steve Mathieu
This document summarizes several recent randomized controlled trials in critical care medicine:
1. A trial comparing high-flow nasal cannula to standard oxygen therapy in patients post-abdominal surgery found no difference in rates of hypoxemia or other outcomes.
2. A trial of intravenous iron in anemic critically ill patients found higher hemoglobin levels at discharge but no difference in transfusion requirements.
3. A trial of dexmedetomidine in elderly surgery patients reduced delirium rates compared to placebo.
Renal denervation is a potential treatment for resistant hypertension that involves ablating the renal nerves to lower blood pressure. The document discusses the epidemiology of hypertension and definitions of resistant hypertension. It then summarizes early clinical trial results from Symplicity HTN-1 and Symplicity HTN-2 that demonstrated reductions in blood pressure out to 3 years with renal denervation. Ongoing studies like the Global SYMPLICITY Registry aim to evaluate real-world outcomes. The document reviews technical considerations for renal denervation and compares various catheter systems for performing the procedure. Long-term data are still needed regarding durability and safety with larger and longer-term studies.
Salon a 14 kasim 09.00 10.15 arzu topeli̇ i̇ski̇t-ingtyfngnc
This document summarizes updates in sepsis epidemiology, diagnosis, and management based on recent guidelines and studies. It notes that sepsis affects millions worldwide each year and is a leading cause of death in hospitals. While guidelines over the past decade have aimed to increase early diagnosis and treatment, compliance remains low and an expected decrease in mortality has not been observed. Ongoing research continues to investigate new diagnostic tools and therapeutic agents for sepsis.
1) The REALITY trial compared a restrictive versus liberal red blood cell transfusion strategy in 630 patients with acute myocardial infarction and mild anemia.
2) The primary outcome of 30-day major adverse cardiovascular events was non-inferior for the restrictive strategy compared to the liberal strategy.
3) A cost-effectiveness analysis found the restrictive strategy had an 84% probability of being the dominant strategy by being both more effective and less costly.
This study evaluated the effect of enoxaparin vs placebo on mortality in acutely ill medical patients. Over 8,300 subjects aged 40+ hospitalized for conditions increasing thrombosis risk were randomized to enoxaparin 40mg daily or placebo for 6-14 days. The primary outcome of 30-day all-cause mortality saw no significant difference between groups. Secondary outcomes including 14-day mortality also showed no differences. Enoxaparin was associated with a significantly increased risk of bleeding. The study was underpowered and its results may have been influenced by use of compression stockings in all patients and lack of risk stratification.
This study examined the prognostic significance of QRS fragmentation (fQRS) in electrocardiograms of adults with tetralogy of Fallot (TOF). The study found that the extent of fQRS strongly predicted all-cause mortality and clinical ventricular arrhythmias. Patients with more severe fQRS involving 5 or more leads had the highest mortality risk. The presence and extent of fQRS provided better prediction of outcomes than QRS duration alone. A simple risk score was created combining factors like fQRS extent, age, and prior procedures to stratify long-term mortality risk in adults with TOF.
1. The document discusses several studies that have evaluated the use of thromboelastography (TEG) or thromboelastometry (ROTEM) to guide blood product transfusion in patients undergoing cardiac surgery or with massive bleeding.
2. The studies found that TEG/ROTEM-guided transfusion protocols may reduce the use of blood products such as fresh frozen plasma, platelets, and total units transfused compared to usual care. However, the evidence is still weak to moderate and did not show significant effects on mortality or other clinical outcomes.
3. Confounding factors between studies include differences in the time points for TEG/ROTEM monitoring, transfusion triggers, and
This document discusses renal denervation as a potential treatment for resistant hypertension. It begins with an introductory case study of a 64-year-old male patient with severe, treatment-resistant hypertension. It then provides details of the patient undergoing renal denervation treatment via catheter ablation of the perirenal sympathetic nerves. Blood pressure measurements before and after the procedure show a significant reduction. The document concludes by outlining the randomized PRAGUE-15 clinical trial that will further evaluate the effectiveness of renal denervation.
This randomized controlled trial studied the effects of synthetic human angiotensin II (LJPC-501) versus placebo in patients with vasodilatory shock across 75 intensive care units in 9 countries. Patients received either LJPC-501 or saline placebo in a 1:1 ratio, with the goal of increasing mean arterial pressure to at least 75 mm Hg. The primary outcome was response in mean arterial pressure at 3 hours. Secondary outcomes included changes in cardiovascular and total organ failure scores. Angiotensin II increased blood pressure and allowed for reductions in catecholamine doses compared to placebo.
This document discusses hypertension and stroke, focusing on intracerebral hemorrhage. It provides information on:
1) Hypertension is a major risk factor for stroke, and strict blood pressure control can prevent up to 45% of strokes. Diastolic blood pressure over 110 mmHg significantly increases stroke risk.
2) Abnormal nocturnal blood pressure patterns like non-dipping or rising are associated with higher cardiovascular risk. Drugs like cilnidipine can help restore normal dipping patterns.
3) Intracerebral hemorrhage caused by hypertension often has poor outcomes but early diagnosis and aggressive blood pressure control below 140 mmHg within 6 hours, as shown in the INTERACT
Is early use of combination therapy the solution 35 minute slide setSoM
1) Combination antihypertensive therapy is more effective at controlling blood pressure and reducing cardiovascular events than monotherapy. Studies show combination therapy lowers blood pressure more than doubling the dose of a single drug.
2) The use of single pill combinations can improve medication adherence compared to free drug combinations. This is due to reducing pill burden and side effects. Improved adherence is associated with better blood pressure control and reduced cardiovascular outcomes.
3) Guidelines now recommend initiating treatment of hypertension with two drugs from different classes in a single pill combination, especially for patients with higher risk or uncontrolled blood pressure on monotherapy. Starting with low doses of multiple agents can provide rapid and effective blood pressure reduction.
The Zika virus is a flavivirus related to dengue, yellow fever, and West Nile viruses. It has a positive-sense RNA genome that can directly produce viral proteins. The genome encodes seven nonstructural proteins that help replicate the RNA and three structural proteins that form the nucleocapsid and envelope. There are two lineages of Zika virus - African and Asian - and the current outbreak strain spreading in the Americas is closely related to the Asian lineage involved in the 2013 French Polynesia outbreak.
Dr. Surendra Ghintala presented on speech disorders. The presentation covered topics such as external versus inner speech, the central language zones of the brain including the receptive and executive areas, the anatomy of language functions, and the components and structure of language including phonology, morphology, syntax, semantics, and pragmatics. Classification systems for aphasia were discussed including the Boston Aphasia Classification System which recognizes eight subtypes of aphasia. Clinical features of different aphasia syndromes were outlined. Motor speech disorders including apraxia and dysarthria were also covered along with other conditions that can cause aphasia such as dialysis dementia syndrome.
This document provides an overview of systemic lupus erythematosus (SLE). It discusses the definition, epidemiology, pathogenesis, diagnosis, clinical manifestations, management, and complications of SLE. The pathogenesis involves genetic susceptibility and environmental triggers leading to abnormal immune responses and autoantibody production. Diagnosis is based on the SLICC classification criteria. Management involves controlling symptoms, preventing organ damage, and treating flares and complications using medications like glucocorticoids, antimalarials, immunosuppressants, and biologics. Life-threatening complications can include renal disease, neurological involvement, hematological abnormalities and vasculitis.
This document provides an overview of myelodysplastic syndrome (MDS). It discusses the history and evolving definitions of MDS. Key points include that MDS is a heterogeneous group of stem cell disorders characterized by cytopenias, dysplasia, and risk of acute myeloid leukemia. The document reviews classification systems including FAB and WHO criteria. It covers pathogenesis, clinical features, risk factors, diagnostic evaluation including blood and bone marrow findings, and molecular abnormalities associated with MDS.
MDS is a clonal hematopoietic stem cell disorder characterized by disordered cell proliferation and impaired differentiation, resulting in cytopenias and risk of progression to leukemia. It commonly affects elderly people over age 70 and has a slight male preponderance. Exposure to radiation, chemotherapy, benzene, and genetic disorders can increase the risk of developing MDS. Cytogenetic abnormalities are found in half of patients and certain mutations are associated with prognosis, such as spliceosome defects correlating with favorable outcomes and mutations in EZH2, TP53, RUNX1, and ASXL1 correlating with poor outcomes.
This document describes a case of a 48-year-old female patient presenting with gradually worsening breathlessness, palpitations, and chest pain. On examination, she was found to have irregular pulse, engorged neck veins, basal lung crepitations, and hepatomegaly. Echocardiography revealed predominant mitral stenosis and mitral regurgitation, enlarged left atrium and right ventricle, and pulmonary hypertension. The provisional diagnosis was rheumatic heart disease with mitral stenosis and regurgitation, pulmonary hypertension, and congestive heart failure. The physician chose to present this case to highlight the importance of bedside cardiology skills and revive awareness of rheumatic heart disease.
This document presents a case of multivalvular heart disease involving the mitral, aortic, and tricuspid valves. On examination, the patient had signs of mitral and aortic stenosis as well as aortic and tricuspid regurgitation. The clinical diagnosis was severe mitral restenosis, severe aortic stenosis, moderate aortic regurgitation, and functional tricuspid regurgitation, likely due to rheumatic heart disease. The document then discusses various topics related to multivalvular heart disease including common causes, factors modifying presentation, features of individual valve lesions, and combinations of lesions.
This document discusses rheumatic heart disease, which is permanent heart valve damage caused by one or more attacks of acute rheumatic fever following a streptococcal throat infection. It covers the epidemiology, pathogenesis, clinical manifestations, diagnosis, and management of rheumatic heart disease. The pathogenesis involves an autoimmune response triggered by the throat infection that causes inflammation of the heart valves. Diagnosis is based on modified Jones criteria and physical exam may reveal murmurs from valve damage. Rheumatic heart disease remains an important cause of morbidity in developing countries.
1. The document discusses a study comparing surgical treatment versus conservative treatment for patients with spontaneous intracerebral hemorrhage who are positive for the "spot sign" on imaging.
2. The study found that while mortality at 90 days was significantly lower in patients who received surgery, there was no significant difference in clinical outcomes like the Glasgow Outcome Scale between the surgical and conservative treatment groups.
3. Therefore, the study concludes that while surgery may reduce mortality risk, it does not clearly provide a clinical outcome benefit over conservative treatment for spot sign positive intracerebral hemorrhage patients.
This document discusses hepatorenal syndrome (HRS), a type of kidney failure seen in patients with advanced chronic liver disease. It defines HRS and outlines its causes, pathophysiology, diagnosis, classification, management, and treatment. Key points include:
- HRS is characterized by severe renal vasoconstriction and dysfunction in the setting of cirrhosis. It has two main types - type 1 is rapidly progressive while type 2 is more gradual.
- Risk factors include large volume paracentesis, infections, bleeding, and other precipitating events. The pathophysiology involves splanchnic vasodilation, renal sympathetic stimulation, cardiac dysfunction, and circulating vasoactive mediators.
This document discusses cardiovascular diseases in HIV patients. It notes that cardiovascular disease is more common in HIV patients due to multiple potential factors, including traditional risk factors, HIV itself, antiretroviral therapy, and chronic inflammation. It also discusses specific cardiac complications in more detail, such as cardiomyopathy, pericardial effusion, endocarditis, pulmonary hypertension, vasculitis, and the possible association between viral infections and coronary artery disease.
This document presents a study on cardiac manifestations and electrocardiographic changes in patients with acute organophosphorus poisoning. The study analyzed hospital records of 100 patients with acute organophosphorus poisoning and found that 90% had tachycardia and 26% had hypertension while 24% had hypotension. Electrocardiograms showed 28% had prolonged QT intervals, 4% had ST changes, and 26% had T wave changes. The study concludes that cardiac complications are common in these patients and require continuous monitoring, even after clinical symptoms improve, as ECG changes can indicate prognosis.
Adult onset Still's disease (AOSD) is a rare inflammatory condition characterized by high spiking fevers, evanescent rash, and joint inflammation. Its cause is unknown but may be triggered by viral or bacterial infections. Diagnosis is based on clinical features including quotidian fevers over 39C, arthritis for 2+ weeks, salmon-pink rash, and exclusion of other conditions. Treatment involves NSAIDs, glucocorticoids, or immunomodulators depending on severity.
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
10 Benefits an EPCR Software should Bring to EMS Organizations Traumasoft LLC
The benefits of an ePCR solution should extend to the whole EMS organization, not just certain groups of people or certain departments. It should provide more than just a form for entering and a database for storing information. It should also include a workflow of how information is communicated, used and stored across the entire organization.
5-hydroxytryptamine or 5-HT or Serotonin is a neurotransmitter that serves a range of roles in the human body. It is sometimes referred to as the happy chemical since it promotes overall well-being and happiness.
It is mostly found in the brain, intestines, and blood platelets.
5-HT is utilised to transport messages between nerve cells, is known to be involved in smooth muscle contraction, and adds to overall well-being and pleasure, among other benefits. 5-HT regulates the body's sleep-wake cycles and internal clock by acting as a precursor to melatonin.
It is hypothesised to regulate hunger, emotions, motor, cognitive, and autonomic processes.
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
Mercurius is named after the roman god mercurius, the god of trade and science. The planet mercurius is named after the same god. Mercurius is sometimes called hydrargyrum, means ‘watery silver’. Its shine and colour are very similar to silver, but mercury is a fluid at room temperatures. The name quick silver is a translation of hydrargyrum, where the word quick describes its tendency to scatter away in all directions.
The droplets have a tendency to conglomerate to one big mass, but on being shaken they fall apart into countless little droplets again. It is used to ignite explosives, like mercury fulminate, the explosive character is one of its general themes.
3. INTERACT 1
• Aimed to determine if early intensive BP lowering is:
– feasible
– safe
– attenuates haematoma expansion
• Sample size (n=400) provided 80% power to detect
17% (≥60% reduction in relative risk) minimum
absolute difference in proportional mean haematoma
growth between randomised groups, assuming 30%
(SD60) mean growth in guideline group.
4. Blood Pressure Management
• Study evaluated a management policy and NOT of
a single agent
• Pragmatic approach to treatment
– Agents used are those available in hospitals
– Agents that are approved for clinical use
– Lower study costs versus packaging and use of placebo
• BP management protocols provided to standardise
therapies across countries
5. INTERACT1 Protocol Scheme
Acute spontaneous ICH
onset < 6 hours
SBP ≥ 150 and ≤ 220 mmHg
No definite indications or contraindications to treatment
Able to be actively managed
Provide informed consent
Repeat CT scans 24 and 72 hrs
Vital signs and BP over 7 days
In-person 28 day and 3 month follow-up
Intensive BP lowering
Target systolic BP 140 mmHg
within 1 hour and for 24+ hrs
Standard BP management
AHA Guideline-based
(treatment if systolic BP >180 mmHg)
R
Standard
best
practice
stroke unit
care
R
6. Measurement of haematoma parameters
• Repeat CTs at 24 and 72 hrs
• DICOM digital CT images sent
to central core lab (Sydney)
• Multi-slice planimetric technique
using MIStar 3.2 software
(Melbourne, Aust)
• Analysed by 2 neurologist
readers blind to clinical, centre,
treatment and time of CT data
8. Patient characteristics
Standard
(n = 201)
Intensive
(n = 203)
Time to randomization,
hr:min median (IQR) 3.4 (2.5-4.5) 3.4 (2.5-4.5)
Age (mean SD), yrs 62 13 63 12
Gender (male) 69% 61%
China 95% 95%
Systolic BP (mean SD) 182 19 180 18
Diastolic BP (mean SD) 105 15 101 14
Heart rate 79 79
NIHSS, median (IQR) 9 (5-16) 9 (5-14)
GCS, median (IQR) 14 (12-15) 14 (13-15)
History of hypertension 74% 74%
Use of antihypertensives 45% 42%
Deep location of hematoma 84% 83%
9. Therapies and management
Standard
(n = 201)
Intensive
(n = 203)
Any blood pressure lowering 74% 98%
Method - bolus 48% 58%
- infusion 66% 73%
Single iv agents 34% 66%
Intubation 9% 7%
Intravenous fluids 98% 98%
Fever treated 39% 36%
Nasogastric feeding 21% 20%
Intravenous mannitol 86% 82%
Neurosurgery intervention 7% 7%
Use of FFP or vitamin K 5% 3%
Use of rFVIIa 3% 6 %
10. INTERACT – Relative increase in haematoma volume for tertiles of
systolic BP, by baseline and achieved levels
Proportionalincrease(%)
150 160 170 180 190 200 210
0
10
20
30
40
50
120 130 140 150 160 170 180
0
50
10
20
30
40
P trend=0.03P trend=0.12
Baseline SBP (mmHg) Achieved SBP (mmHg)
Adjusted for age, sex, haematoma location, baseline haematoma volume, time from onset to CT, and study treatment.
Arima et al. J Hypertension 2010; 56:852-858
11. INTERACT: Reduction in absolute hematoma growth over 72
hours according to time from onset to treatment
Reduction
in
Volume
6.5 ml
3.3 ml
0.9 ml
0.6 ml
Intensive
-4.4 ml
0.1 ml
-1.1 ml
-0.2 ml
Guideline
2.1 ml
3.4 ml
-0.2 ml
0.4 ml
Absolute growthTime from onset
to treatment
<2.9h
2.9-3.6h
3.7-4.8h
≥ 4.9h
Favors
intensive
Favors
guideline
Reduction in hematoma growth over 72h (ml)
15 0 -510 5
Time from onset
to treatment Intensive Guideline
Unpublished data
12. Interact: Reduction in relative hematoma growth over 72 hours
according to time from onset to treatment
Reduction
In
volume
21%
15%
7%
4%
Intensive
-10%
16%
-6%
19%
Guideline
10%
31%
1%
22%
Favors
intensive
Relative growth
Favors
guideline
Reduction in hematoma growth over 72h (%)
30 0
P for
trend
0.02
Time from
onset
<2.9h
2.9-3.6h
3.7-4.8h
≥ 4.9h
-1020 10
Time from onset
to treatment
P for
trend
Unpublished data
14. Clinical outcomes (90 days)
Standard
(n = 201)
Intensive
(n = 203)
p
Death or dependency 49 48 0.81
Death 12 10 0.51
Dependency 41 36 0.98
Modified Rankin Score, median 2 2 0.66
NIHSS, median 2 2 0.97
Barthel Index Score, median 95 95 0.77
MMSE, median 28 27 0.97
EuroQoL, EQ5D, median, % 78 75 0.97
15. Conclusion
• INTERACT1 shows consistency of the BP lowering
treatment effect across various different analyses
BP lowering on haematoma growth at 24 and 72
hours
Haematoma rather than perihaematoma oedema
is the principle therapeutic target
Lower BP levels (140-150 mmHg) are likely to
produce greater benefits
Early BP lowering are likely to produce greater
benefits
16. Conclusion (cont.)
• Early rapid BP lowering is:
– clinically feasible
– not associated with excess hazard
– appears to reduce haematoma expansion
• However, some limitations:
– single study, mainly Chinese participants
– potential play of chance
– no effect on clinical outcomes, as in rFVIIa
studies
17. Conclusion (cont.)
Recommendations
1.Until ongoing clinical trials of BP intervention for ICH are completed,
physicians must manage BP on the basis of the present incomplete efficacy
evidence. Current suggested recommendations for target BP in various
situations are listed in Table 6 and may be considered (Class IIb; Level of
Evidence: C). (Unchanged from the previous guideline)
2.In patients presenting with a systolic BP of 150 to 220 mmHg, acute lowering
of systolic BP to 140 mmHg is probably safe (Class IIa; Level of Evidence: B).
(New recommendation)
18. Summary
• INTERACT shows that early intensive BP lowering with
careful monitoring is:
feasible, safe, and attenuates hematoma growth
• As antihypertensive agents are inexpensive and widely
available
widespread adoption of a standard policy could
translate into high absolute benefits
• A large-scale trial powered to evaluate modest but still
worthwhile effects on clinical endpoints is required to
influence clinical practice
21. Method:
INTERACT2 is a clinical study involving 2800 patients with acute ICH recruited from
approximately 140 centres around the world. Not only this is a global study, it is the
largest study that has ever been conducted on ICH.
Eligible participants are allocated to receive either intensive blood pressure lowering
treatment, or the currently recommended (more conservative) blood pressure
management.
Trial Progression:
Participant recruitment for INTERACT2 began in October 2008. Approximately 140
centres from around the world participated in the trial and this includes centres in
Australia, Europe, China, India, Africa, and North and South America. Trial recruitment
was completed on 31st August 2012, with a total of 2839 patients recruited.
WHAT IS INTERACT 2 TRIAL?
22. INTRODUCTION
• Acute intracerebral hemorrhage which is the least treatable
form of stroke ,affects more than 1 million people worldwide
annually with the outcome determined by the volume and
growth of the underlying hematoma.
• Blood pressure often becomes elevated after intracerebral
hemorrhage, frequently reaching very high levels, and is a
predictor of outcome.
• On the basis of the results of the pilot-phase study, Intensive
Blood Pressure Reduction in Acute Cerebral Hemorrhage
Trial 1 (INTERACT1) a main-phase study, INTERACT2 was
conducted to determine the safety and effectiveness of early
intensive lowering of blood pressure in patients with
intracerebral hemorrhage
23. TRIAL DESIGN
• INTERACT2 was an international, multicenter, prospective,
randomized, open-treatment, blinded end-point trial.
• In brief, the effect of a management strategy was compared :-
. targeting a lower systolic blood pressure within 1 hour, with
the current guideline-recommended strategy which targets a
higher systolic blood pressure in patients who had a systolic
blood pressure between 150 and 220 mm Hg and who did not
have a definite indication for or contraindication to blood-
pressure–lowering treatment that could be commenced
within 6 hours after the onset of spontaneous intracranial
hemorrhage
24. • Reduced number of in-hospital assessments but includes
an assessment of ICU stay and use of renal dialysis
• Repeat 24 hr CT scan to be collected only in 600 patients
(300 Chinese and 300 non-Chinese)
• Option of telephone-based outcome assessments at 28
and 90 days
• Screening logs kept for only 1 month of the year
– sites to be notified of the randomly selected month
in advance.
• Use of an Interactive Voice Randomisation System (IVRS)
in China
INTERACT2: New design features
25. INTERACT2 BP Management
• Evaluation of a management policy and NOT
of a single agent
• Inclusion of BP lowering management
protocols for key available agents
• Pragmatic approach to treatment
• Agents readily available in hospitals
• Agents approved for clinical use
• Lower study costs
26. Study Outline
Acute spontaneous ICH
onset <6 hours
SBP ≥150 and ≤220 mmHg
No definite indications or contraindications to treatment
Able to be actively managed
Provide informed consent
Repeat CT scans 24 hrs in selected patients
Vital signs and BP over 7 days
28 day and 3 month follow-up
IntensiveBP lowering
Target systolic BP 140 mmHg
within 1 hour and for 24+ hrs
Conservative BP management
AHA Guideline-based
(treatment if systolic BP >180 mmHg)
R
Standard
best
practice
stroke unit
care
27. Sample Size
• 2800 patients from 140+ sites
• 90% power for:
– 14% RRR in death/dependency in active vs
control
– 20% RRR in (50%) randomised<4 hours
28. Network
Australia
14 centres
China
49 centres
India
/Pakistan
13 centres
USA
(Rochester)
1 centre
Chile
6 centres
Argentina
6 centres
Brazil
9 centres
Europe
Austria, Finland, France,
Germany, Portugal, Spain,
Switzerland, The Netherlands,
Italy, Poland
64 centres
UK
27 centres
29. Inclusion Criteria
• Age 18 years or above
• Acute spontaneous ICH (history and CT)
• At least two systolic BP 150-220 mmHg,
recorded ≥2 min apart
• Able to be randomly assigned BP lowering
therapy within 6 hours of stroke onset
• Able to receive active (‘intensive’) care in a
monitored facility
30. Exclusion Criteria
• Known definite contraindication to intensive
BP lowering
• Known definite indication to intensive BP
lowering
• ICH secondary to a structural abnormality
• Ischemic stroke in last 30 days
• High likelihood of death within 24 hours (GCS
3-5)
31. Exclusion Criteria (cont.)
• Known advanced dementia or significant pre-
stroke disability
• Concomitant medical illness
• Planned early surgical intervention
• Participation in other trial
• Unlikely to adhere to treatment or follow-up
32. Eligibility
To be eligible for INTERACT2:
• All inclusion criteria questions must be
answered “YES”
• All exclusion criteria questions must be
answered as “NO”
33. Randomisation system
Patients are stratified according to: time since stroke onset (0-4
vs. 4-6 hours), site and country of recruitment
Randomised to either
Intensive BP lowering
treatment
Control; current
guideline based
management of BP
34. RANDOMIZATION
• Investigators entered baseline data into a database
associated with a secure Web-based randomization
system.
• The data were checked to confirm the eligibility of the
patient, and several key clinical variables were
recorded before the system assigned a participant to
intensive or guideline-recommended management of
blood pressure with the use of a minimization
algorithm to ensure that the groups were balanced
with respect to country, hospital, and time (≤4 hours
vs. >4 hours) since the onset of the
intracerebralhemorrhage
35. Protocol scheme
from INTERACT1 (Lancet Neurol 2008) and (Int J Stroke 2010)
Acute spontaneous ICH confirmed by CT/MRI
Definite time of onset within 6 hours
Systolic BP 150 to 220 mmHg
No indication/contraindication to treatment
In-hospital vital signs, NIHSS, GCS and BP over 7 days
Intensive BP lowering
SBP <140 mmHg
Standard BP management
Guidelines SBP <180 mmHg)
R
35
Independent 90 day outcome with
modified Rankin scale (mRS)
N=2800 gives 90% power for
7% absolute (14% relative)
decrease (50% standard vs
43% intensive) in outcome
36. Patient Flow – 2839 patients recruited
October 2008 to August 2012
1382 (98.5%) for primary outcome 1412 (98.3%) for primary outcome
2839 Randomised
28,829 Total estimated screened
3 no consent
1 missing baseline data
2 lost to follow-up
3 withdrew consent
12 alive without mRS data
Reasons for exclusion (n=3572)
39% Outside time window
16% Judged unlikely to benefit
11% BP outside criteria
8% Planned early surgery
5% Refused
21% Other reasons
6411 Screening logs completed
1403 Intensive BP lowering 1436 Standard BP lowering
5 no consent
1 missing baseline data
5 lost to follow-up
4 withdrew consent
9 alive without mRS data
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52. Systolic BP time trends
1 hour - Δ14 mmHg (P<0.0001)
6 hour - Δ14 mmHg (P<0.0001)
Systolic BP control
Median (iqr) time to treatment, hr - intensive 4 (3-5), standard 5 (3-7)
Intensive group to target (<140mmHg)
462 (33%) at 1 hour
731 (53%) at 6 hours
MeanSystolicBloodPressure(mmHg)
0
110
120
130
140
150
160
170
180
190
200
R 15 30 45 60 6 12 18 24 2 3 4 5 6 7
Standard
Intensive
////
Minutes Hours Days / Time
164
153
150
139
am pm am pm am pm am pm am pm am pm
P<0.0001
beyond 15mins
Target level
52
54. Management - Baseline to Day 7
Variable
Intensive
(N=1399)
Standard
(N=1430)
Intubation 7% 7%
ICU admission 39% 38%
DVT prophylaxis 22% 22%
Intravenous mannitol 62% 61%
Surgery 6% 6%
evacuation/decompression 3% 3%
ventricular drain 3% 3%
*all non-significant
54
55. Primary clinical outcome
Death or major disability (mRS 3-6) at 90 days
12.0 12.0
40.0
43.6
0
10
20
30
40
50
60
Intensive Standard
Major
Disability
(3-5)
Death (6)
%
(N=1399) (N=1430)
52.0%
55.6%
Odds ratio 0.87 (95%CI 0.75 to 1.01) P=0.06
55
Among survivors
Odds Ratio 0.85
(95%CI 0.73-0.99)
P=0.05
56. Key secondary outcome
Ordinal shift in mRS scores (0-6)
Odds ratio 0.87 (95%CI 0.77 to 1.00); P=0.04
56
18.0% 18.8% 16.6% 19.0%
12.0%8.0%
0 1 2 3 4 5 6
Intensive
Standard
Major disability DeathDisability but independent
18.7% 15.9% 18.1% 6.0%21.1%8.1% 12.0%
7.6%
57. Standard (0-2 vs 3-6)
Crude
Adjusted*
Other (0-1 vs 2-6)
Crude
Adjusted*
Other shift analysis
0
1
2
3
versus 4+5+6
Crude
Adjusted*
Intensive
719 (52.0)
978 (70.8)
112 (8.1)
292 (21.1)
259 (18.7)
220 (15.9)
499 (36.1)
Standard
785 (55.6)
1051 (74.4)
107 (7.6)
254 (18.0)
266 (18.8)
234 (16.6)
551 (39.0)
Odds ratio (95%CI)
0.87 (0.75 to 1.01)
0.87 (0.74 to 1.04)
0.83 (0.70 to 0.98)
0.85 (0.70 to 1.03)
0.87 (0.76 to 0.99)
0.88 (0.76 to 1.02)
P value
0.06
0.12
0.03
0.09
0.04
0.08
0.5 1.0 2.0
Odds ratio
(95% CI)
Intensive
Better
Standard
Better
Number of events (%)
Sensitivity analysis – crude and adjusted measures of
primary endpoint and with different mRS cut-points
57
*adjusted for prognostic variables: age, NIHSS score, time
from ICH to randomisation, haematoma volume and
location, and intraventricular haemorrhage
58. 58
Age
<65 years
≥65 years
Region
Chinese
Others
Time to randomisation
<4 hours
≥4 hours
Baseline systolic BP
<180 mmHg
≥180 mmHg
History of hypertension
Yes
No
Baseline NIHSS score
<15
≥15
Baseline haematoma volume
<15 ml
≥15 ml
Baseline haematoma location
Deep
Others
Total
Intensive
340 (43.3)
379 (63.6)
431 (45.8)
288 (65.5)
435 (54.3)
284 (48.9)
372 (50.0)
347 (54.4)
524 (52.5)
194 (50.7)
393 (39.8)
324 (82.9)
285 (39.3)
383 (69.1)
568 (53.1)
100 (47.6)
719 (52.0)
Standard
352 (46.7)
433 (65.7)
480 (49.6)
305 (68.7)
465 (56.7)
320 (54.1)
400 (53.8)
385 (57.6)
555 (54.3)
228 (58.9)
440 (44.3)
341 (83.4)
309 (42.0)
416 (73.4)
614 (56.9)
111 (49.8)
785 (55.6)
Odds Ratio (95%CI)
0.87 (0.71 to 1.06)
0.91 (0.72 to 1.15)
0.86 (0.72 to 1.03)
0.86 (0.65 to 1.14)
0.91 (0.75 to 1.10)
0.81 (0.65 to 1.02)
0.86 (0.70 to 1.05)
0.88 (0.70 to 1.09)
0.93 (0.78 to 1.11)
0.72 (0.54 to 0.95)
0.83 (0.70 to 0.99)
0.96 (0.67 to 1.40)
0.90 (0.73 to 1.10)
0.81 (0.63 to 1.05)
0.86 (0.73 to 1.02)
0.92 (0.63 to 1.34)
0.87 (0.75 to 1.01)
P homog
0.76
0.97
0.48
0.90
0.12
0.48
0.57
0.76
0.5 1.0 2.0
Odds Ratio (95%CI)
Intensive
Better
Guideline
Better
Number of events (%)
Pre-specified subgroups
and primary endpoint
59. Health-related quality of life
EuroQol EQ-5D domains ‘any problems’ versus ‘no problems’
64
47
61
40
34
67
52
66
45
38
0
10
20
30
40
50
60
70
80
Intensive Standard
P=0.02
P=0.006
P=0.05
% with problems
P=0.13
P=0.01
59
Health utility - 0.6 intensive vs 0.55 standard groups; P=0.002
60. Other secondary clinical outcomes
Parameter
Intensive
(N=1399)
Standard
(N=1430) P
Hospital stay, median (IQR) days 20 (12-35) 19 (11-33) 0.43
Institutional care at 90 days 9% 9% 0.80
Poor outcome at 28 days 66% 68% 0.22
60
Neurological deterioration
in first 24 hours
(≥4 NIHSS or ≥2 GCS)
66% 68% 0.22
61. Safety - cause-specific mortality, n(%)
Cause of Death
Intensive
(N=1394)
Standard
(N=1421) P
Direct effects of primary ICH event 103 (7.4) 111 (7.8) 0.67
Cardiovascular disease 14 (1.0) 15 (1.1) 0.90
ICH 0 (0.0) 2 (0.1)
Ischaemic/undifferentiated stroke 1 (0.1) 1 (0.1)
Acute MI/coronary event/other 3 (0.2) 1 (0.1)
Other vascular disease 2 (0.1) 2 (0.1)
Other cardiac disease 8 (0.6) 9 (0.6)
Non-cardiovascular disease 50 (3.6) 45 (3.2) 0.54
Renal failure 2 (0.1) 2 (0.1)
Respiratory infections 17 (1.2) 12 (0.8)
Sepsis (includes other infections) 6 (0.4) 4 (0.3)
Non-vascular medical 25 (1.8) 27 (1.9)
61
62. Safety - non-fatal serious adverse events (SAEs), n(%)
Serious Adverse Event
Intensive
(N=1399)
Standard
(N=1430) P
Direct effects of primary ICH event 47 (3.4) 55 (3.8) 0.49
Cardiovascular disease 37 (2.6) 41 (2.9) 0.72
ICH 4 (0.3) 4 (0.3)
Ischaemic/undifferentiated stroke 8 (0.6) 8 (0.6)
Acute MI/coronary event/other 5 (0.4) 5 (0.3)
Other vascular disease 13 (0.9) 14 (1.0)
Other cardiac disease 9 (0.6) 12 (0.8)
Non-cardiovascular disease 160 (11.4) 152 (10.6) 0.49
Renal failure 5 (0.4) 7 (0.5)
Severe hypotension 7 (0.5) 8 (0.6) 0.83
Respiratory infections 48 (3.4) 53 (3.7)
Sepsis (includes other infections) 21 (1.5) 20 (1.4)
Non-vascular medical /injury 132 (9.4) 125 (8.7)
62
63. • Early intensive BP lowering treatment is:
safe - no increase in death or harms
effective – borderline significant effect on the primary
endpoint
secondary analyses - improved recovery of physical
functioning and health-related quality of life in
survivors
• Consistent direction of effect in sensitivity analyses
• No heterogeneity of the treatment effect across different
patient and disease characteristics
Major findings of INTERACT2
63
64. • Treatment effect smaller (4%) than expected 7%
absolute, but:
active-comparison study on background therapies, some
with BP lowering properties (i.e. mannitol)
equates to NNT 25 (greater than aspirin and near late use
of rtPA in ischaemic stroke)
• No clear time-dependent relationship of treatment
potential mechanisms beyond haematoma growth
benefits of BP control may take several hours to manifest
INTERACT2 - issues
64
65. • Moreover, there was no evidence of a
significant effect modification according to a
history or no history of hypertension — a
finding that is relevant because it has been
postulated that patients with hypertension
have an upward shift in cerebral
autoregulation and possibly an increased risk
of cerebral ischemia related to intensive
lowering of blood pressure
66. • INTERACT2 resolves longstanding uncertainty over the
management of elevated BP in acute ICH
• Provides evidence regarding safety and efficacy in a
broad range of patients with ICH
• Defines for the first time a medical therapy for the
management of acute ICH
• As BP lowering treatment is low cost, simple to
implement, and widely applicable, the treatment
should become standard of care to patients with ICH in
hospitals all over the world
Conclusions
66
67. • BP lowering in acute ICH is safe, so ……
Go early
Go intensive (target systolic BP 140 mmHg)
Go sustained (≥24 hours)
• in most patients
• improves chances of better recovery in
survivors
Take home message
67
69. OUTILNE
• Implications for clinical
practice guidelines
– Statistical significance
• Implications for
clinicians at bedside
– Clinical significance
– Systems of care
• Implications for future
UCLA Stroke Center
73. INTERACT 2: A Near Win Trial
Trial Intervention OR P
primary
P
ordinal
INTERACT 2 BP↓ for ICH 0.87 (0.75-1.01) 0.06 0.04
UCLA Stroke Center
74. Stroke and Near Win Trials
Trial Intervention OR P
primary
P
ordinal
INTERACT 2 BP↓ for ICH 0.87 (0.75-1.01) 0.06 0.04
IST 3 TPA to 6 hours 1.13 (0.95-1.35) 0.18 0.001
SPS3 BP Arm BP↓ prevent
recurrent stroke
0.81 (0.64-1.03) 0.08
UCLA Stroke Center
84. Benefit Over All Health State
Transitions
• Benefit per Thousand:
81
• NNT: 12.3
UCLA Stroke Center
85. Benefit in INTERACT 2 vs Other
Acute Stroke Interventions
Intervention Net Benefit per Thousand
TPA under 3h 290
IA Pro-UK 208
Coiling in SAH 169
TPA 3-4.5h 136
BP lowering for ICH 81
Clinician worthwhile 50
Socioeconomic model worthwhile 20
UCLA Stroke Center
--Samsa et al, Am Heart J 1998;136:703-13
--Saver, Stroke 2007;38:3055-3062
--Saver et al, Stroke 2009;40:2433-7
86. Door to BP Control in Community
Practice in ICH
• 100 patients, 32 Emergency
Departments
• At ED arrival
– NIHSS 18
– Time from LKW 63 mins
– Mean BP 176/94
• 54% received BP therapy in ED
• Among the 48 patients with SBP ≥
180
– Control (<180) never achieved in
19%
– Median door to control 118 mins
– Door to control ≤ 90m in 31%
UCLA Stroke Center
--Sanossian et al, Ann Emerg Med 2012;60: S56
87. Other Treatment Recommendations
for ICH
• ICU monitoring
• Antipyretics in febrile patients
• Early mobilization
• ICP management
– Head of bed, analgesia, sedation
– Osmotic diuretics, CSF drainage,
hyperventilation
• Maintain serum glucose < 185
• Seizures
– Prophylactic antiepileptics for
lobar ICH
– Antiepileptics for clinical seizures
– Antiepileoptics for electrographic
seizures
• DVT prophylaxis
– Intermittent compression on
arrival
– SQ LMWH or UH after 3-4d
• For DVT, consider vena cava filter
• Reversal of coagulopathies
– Protamine for heparin
– Vitamin K, PCC, rF7 for warfarin
• Surgery
– Definite for select cerebellar
– Consider for lobar
– Consider minimally invasive for
deep
UCLA Stroke Center
--Morgenstern et al, Stroke 2010
88. ICH Critical Pathway
Identify Signs of Possible Stroke
Critical EMS Assessments & Actions
Immediate General Assessment/Stabilization
Immediate Neurologic Assessment
(stroke team or designee)
Does CT scan show
hemorrhage?
No Hemorrhage Hemorrhage
Possible
ischemic stroke
Consult neurologist or neurosurgeon
If not available, consider transfer
BP Management
ICP Management
Seizure Prevention and
Management
Fluid Management
Body Temperature
Management
Surgical Treatment of ICH
Cerebellar hemorrhage >3 cm with
neurologic deterioration or brain
stem compression and/or
hydrocephalus
Consider in lobar clots <1 cm of
surface
AHA Adult Stroke Guidelines. Circulation. 2005;112(suppl 24):IV-111-IV-120; Broderick J,
et al. Stroke. 2007;38:2001-2023; Qureshi AI, et al. N Engl J Med. 2001;344:1450-1460.
NINDS
Time Goals
Monitor Blood Glucose
and Treat (if needed)
Begin ICH Pathway
Admit to stroke unit (if available) or ICU
Monitor BP and treat (if indicated)
Monitor neurologic status
(emergent CT if deterioration)
Monitor blood glucose & treat (if needed)
Supportive therapy
Treat comorbidities
89. Time is Brain for Hemorrhagic Stroke
UCLA Stroke Center
--Arima et al, Stroke 2012;43:2236-
8
90. Dynamics of Hyperacute Hematoma Growth
0-120 Minutes: Not Well Delineated
--Kazui et al, Stroke 1996;27:1783-1787
91. Intracerebral Hemorrhage and the
Golden Hour
• Narrow therapeutic time
window
• Early intervention critical
• Prehospital personnel
– 35-70% of stroke patients
arrive by ambulance
– Unique position: first
medical professional to
come in contact with stroke
patient
UCLA Stroke
Center
92. 0
5
10
15
20
25
30
35
40
45
-15 -5 0 20 30 40 60 100 160 200 360
Time in minutes from onset of symptoms
VolumeofHematomainmL
Rupture of
blood vessel
Onset of
Symptoms
Activation
of EMS
EMS
Arrival
EMS Arrival
in ED
Initial ED
Evaluation
CT scan
obtained
CT scan
evaluated
Hospital
Treatment
initiated
Final Hematoma
Volume Established
Sanossian, FAST-BP Trial
93. 0
5
10
15
20
25
30
35
40
45
-15 -5 0 20 30 40 60 100 160 200 360
Time in minutes from onset of symptoms
VolumeofHematomainmL
Rupture of
blood vessel
Onset of
Symptoms
Activation
of EMS
EMS
Arrival
EMS Arrival
in ED
Initial ED
Evaluation
CT scan
obtained
CT scan
evaluated
Hospital
Treatment
initiated
Final Hematoma
Volume Established
Field
Treatment
Initiated
Goal: Control
Hematoma expansion
Earlier in Course
Sanossian, FAST-BP Trial
94. 0
5
10
15
20
25
30
35
40
45
-15 -5 0 20 30 40 60 100 160 200 360
--All hypertensive pts
--All severely hypertensive
pts
Time in minutes from onset of symptoms
VolumeofHematomainmL
Rupture of
blood vessel
Onset of
Symptoms
Activation
of EMS
EMS
Arrival
EMS Arrival
in ED
Initial ED
Evaluation
CT scan
obtained
CT scan
evaluated
Hospital
Treatment
initiated
Final Hematoma
Volume Established
Field
Treatment
Initiated
Goal: Control
Hematoma expansion
Earlier in Course
Sanossian, FAST-BP Trial
95. Onset to Treatment Times in Recent
Trials Enrolling ICH Patients
Trial Setting Intervention Onset to Treatment
INTERACT 1 Hospital Target SBP ≤ 140 4h 00m
ATACH 1 Hospital Nicardipine 4h 17m
INTERACT 2 Hospital Target SBP ≤ 140 4h 00m
RIGHT Prehospital Glyceryl trinitrate 55m
PIL-FAST Prehospital Lisinopril 1h 17m
FAST-MAG Prehospital Magnesium 47m
UCLA Stroke Center
96. Preserve / Treat / Cure
Condition EMS ED OR/Cath Lab
Acute ischemic
stroke
Neuroprotection TPA Endovascular
recanalization
Acute
intracerebral
hemorrhage
BP lowering Hemostatic agent Minimally invasive
hem evacuation
UCLA Stroke Center
97. Preserve / Treat / Cure
Condition EMS ED OR/Cath Lab
Acute ischemic
stroke
Neuroprotection TPA Endovascular
recanalization
Acute
intracerebral
hemorrhage
BP lowering Hemostatic agent Minimally invasive
hem evacuation
UCLA Stroke Center