LandmarkRCT

ATACH-2

Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage

New England Journal of Medicine, 2016 · International, multicenter, randomized controlled trial

Clinical question

Does very intensive systolic blood-pressure reduction improve outcome compared with standard reduction in acute spontaneous intracerebral hemorrhage?

Population: Adults with spontaneous intracerebral hemorrhage, GCS ≥5, hematoma volume <60 cm3, treated within 4.5 hours of symptom onset.
Inclusion criteria: Spontaneous intracerebral hemorrhage
GCS ≥5
Hematoma volume <60 cm3
Treatment started within 4.5 hours
Intervention: IV nicardipine-based intensive treatment targeting SBP 110–139 mmHg.
Comparator: Standard treatment targeting SBP 140–179 mmHg.
Primary outcome: Death or disability (modified Rankin Scale 4–6) at 3 months.
Secondary outcomes: Serious adverse events
Renal adverse events
Result: Very intensive SBP reduction did not improve death/disability and was associated with more renal adverse events. (No significant improvement in the primary outcome)

What the trial found

Targeting SBP 110–139 mmHg was not superior to a 140–179 mmHg target for death or disability after acute ICH.

Current guideline position

Consistent with 2022 AHA/ASA guidance favoring a target around 140 mmHg and maintenance around 130–150 mmHg in selected patients rather than very intensive lowering.

Clinical interpretation

Supports smooth BP control while avoiding routine overshoot below the contemporary 130–150 mmHg maintenance range in suitable mild-to-moderate ICH.

Limitations

The trial tested a very intensive target and does not establish one universal BP target for all ICH severity groups.

High certainty

Clinical Context & Relevant Topics (1)

Disease Reference

Intracranial Hemorrhage: ICH & SAH

Spontaneous ICH vs Aneurysmal SAH, INTERACT-2/ATACH-2 blood pressure targets, emergency anticoagulant reversal, ENRICH minimally invasive evacuation, ISAT coiling, and Nimodipine for delayed cerebral ischemia.

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