Early Intensive BP Reduction After ICH: Risk of Overshooting and Outcomes
Authors: Shi AC, Taylor T, Huang C-C, Singhal AB, Goldstein JN, Bevers MB, Hou PC
Journal: Annals of Emergency Medicine, December 2025
Conclusions:
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In spontaneous ICH, hitting SBP ≤150 mm Hg within 2 hours of ED arrival was associated with worse functional outcomes at discharge (mRS 4–6).
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Overshooting (SBP <120 mm Hg within 6 hours) was also associated with worse outcomes—suggesting harm from excessive early lowering.
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Antihypertensive strategy (bolus vs infusion) did not change overshoot risk.
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Practical takeaway: prioritize controlled, titrated BP reduction and avoid SBP <120 early; aggressive time-to-target efforts may over-shoot and correlate with poorer function. (Observational data—beware confounding by indication.)
Results:
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N=420 spontaneous ICH; 2017–2023, 2 academic centers.
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Arrival SBP >150: 323 (76.9%).
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Antihypertensives ≤1 hr: 62.8%.
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Achieved ≤150 by 2 hrs: 71.2%.
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Outcomes (adjusted):
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Goal ≤150 by 2 hrs → worse outcome: OR 2.32 (95% CI 1.17–4.57).
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Overshoot <120 by 6 hrs → worse outcome: OR 2.55 (95% CI 1.27–5.13).
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Medication type (bolus vs infusion): no association with overshooting.
Methods:
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Retrospective cohort of adult spontaneous ICH.
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Exposure: early BP control (≤150 by 2 hrs) and overshoot (<120 by 6 hrs).
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Outcome: discharge mRS, dichotomized good (0–3) vs poor (4–6).
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Logistic regression adjusted for ICH score, time from last seen well, and arrival BP.
Shi, A.C., Taylor, T., Huang, C.C., Singhal, A.B., Goldstein, J.N., Bevers, M.B. and Hou, P.C., 2025. Early Intensive Blood Pressure Reduction After Intracerebral Hemorrhage Is Associated With Worse Functional Outcome: The Risk of Overshooting Blood Pressure Goals. Annals of Emergency Medicine.