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Abstract
Background: clinical practice guidelines (CPGs) recommend intensive antihypertensive reduction for the management of blood pressure (BP) in people with spontaneous intracerebral hemorrhage (ICH). However, clinical trials (CTs) and systematic reviews (SR) published after the most recent CPGs, have issued different conclusions to the recommendations, maintaining the clinical debate on the decision of the best antihypertensive treatment.
Objectives: to describe the characteristics and quality of most recent CPGs, and to compare their recommendations with the SR and CTs on BP management.
Methods: we systematically searched for CPGs that had recommendations for BP management in people with ICH. Additionally, we searched for SRs and CTs that assessed the safeness and effectiveness of intensive, compared to standard, BP reduction treatment. The search was done in January 2019 in three databases, and there were no restrictions on language. Two independent authors selected the studies, extracted information, and assessed the quality (AGREE-II (Appraisal of Guidelines for Research and Evaluation) for CPGs, AMSTAR-II (A MeaSurement Tool to Assess systematic Reviews) for SRs, and RoB-2 (Risk of bias) for CTs).
Results: we included six CPGs, of which 2/6 had a score ≥ 60% in domain 3 (rigor of development), and 1/6 had a score ≥ 70% in overall evaluation of AGREE-II, 1/6 used GRADE methodology. We included seven SRs, of which 3/7 had a score ≥ 11 in AMSTAR-II. In addition, 2/7 totally supported intensive BP reduction, 4/7 partially supported intensive BP reduction (it fails to improve clinical outcomes, its evidence is insufficient, but appears to be safe), and 1/7 did not recommend it (lack of evidence), while 1/7 found that intensive BP reduction was associated with renal failure (RR=2.18; 95% CI: 1.08-4.41). We included nine CTs, of which 1/9 was not randomized, 5/9 were open-label, and 4/9 had a high risk of bias arising from the randomization process (RoB-2) in six outcomes. In 1/9 researchers used lisinopril and labetalol, in 1/9 nicardipine was used, and in 7/9 any available BP lowering agents were used. The population was small (< 100 patients) in 3/9 CTs, and 2/9 studied ≥ 1000 subjects.
Conclusions: most of the evaluated CPGs did not take into account the patient’s viewpoints, but did have a high score in the rigor of development domain. CPG supports the use of the intensive BP reduction, however, recent systematic reviews partially supported or did not support it, possibly due to the association with renal failure, and the risk of bias of assessed clinical trials. We propose that using intensive BP reduction can have the same effect as standard reduction, and may produce adverse effects in ICH patients, therefore standard reduction is the safest and most effective pathway to reduce high BP in ICH.
Patient or healthcare consumer involvement: this study seeks to contrast the CPG recommendations with the findings of CTs and SR to clarify which antihypertensive target physicians should choose for the benefit of patients.
Objectives: to describe the characteristics and quality of most recent CPGs, and to compare their recommendations with the SR and CTs on BP management.
Methods: we systematically searched for CPGs that had recommendations for BP management in people with ICH. Additionally, we searched for SRs and CTs that assessed the safeness and effectiveness of intensive, compared to standard, BP reduction treatment. The search was done in January 2019 in three databases, and there were no restrictions on language. Two independent authors selected the studies, extracted information, and assessed the quality (AGREE-II (Appraisal of Guidelines for Research and Evaluation) for CPGs, AMSTAR-II (A MeaSurement Tool to Assess systematic Reviews) for SRs, and RoB-2 (Risk of bias) for CTs).
Results: we included six CPGs, of which 2/6 had a score ≥ 60% in domain 3 (rigor of development), and 1/6 had a score ≥ 70% in overall evaluation of AGREE-II, 1/6 used GRADE methodology. We included seven SRs, of which 3/7 had a score ≥ 11 in AMSTAR-II. In addition, 2/7 totally supported intensive BP reduction, 4/7 partially supported intensive BP reduction (it fails to improve clinical outcomes, its evidence is insufficient, but appears to be safe), and 1/7 did not recommend it (lack of evidence), while 1/7 found that intensive BP reduction was associated with renal failure (RR=2.18; 95% CI: 1.08-4.41). We included nine CTs, of which 1/9 was not randomized, 5/9 were open-label, and 4/9 had a high risk of bias arising from the randomization process (RoB-2) in six outcomes. In 1/9 researchers used lisinopril and labetalol, in 1/9 nicardipine was used, and in 7/9 any available BP lowering agents were used. The population was small (< 100 patients) in 3/9 CTs, and 2/9 studied ≥ 1000 subjects.
Conclusions: most of the evaluated CPGs did not take into account the patient’s viewpoints, but did have a high score in the rigor of development domain. CPG supports the use of the intensive BP reduction, however, recent systematic reviews partially supported or did not support it, possibly due to the association with renal failure, and the risk of bias of assessed clinical trials. We propose that using intensive BP reduction can have the same effect as standard reduction, and may produce adverse effects in ICH patients, therefore standard reduction is the safest and most effective pathway to reduce high BP in ICH.
Patient or healthcare consumer involvement: this study seeks to contrast the CPG recommendations with the findings of CTs and SR to clarify which antihypertensive target physicians should choose for the benefit of patients.
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