RCT

INTERACT-2

Rapid Blood-Pressure Lowering in Patients with Acute Intracerebral Hemorrhage

NEJM, 2013 · International multicenter randomized open-label trial (n=2839)

Clinical question

Does intensive acute blood pressure lowering targeting SBP < 140 mmHg improve outcomes in acute intracerebral hemorrhage?

Population: Adults with spontaneous intracerebral hemorrhage within 6 hours of onset and elevated SBP (150-220 mmHg)
Intervention: Intensive blood pressure lowering targeting SBP < 140 mmHg within 1 hour
Comparator: Standard guideline blood pressure lowering targeting SBP < 180 mmHg
Primary outcome: Death or major disability (mRS 3-6) at 90 days
Result: Intensive lowering did not significantly reduce the primary composite outcome of death or major disability (52.0% vs 55.6%, P=0.06), but ordinal analysis of mRS showed significantly improved functional recovery (odds ratio 0.87, 95% CI 0.77-1.00, P=0.04) with no safety concerns.

What the trial found

Intensive BP lowering toward <140 mmHg was safe and did not significantly reduce the primary composite of death or major disability; an ordinal mRS analysis showed a modest shift toward better functional outcome. Hematoma-growth effects were not sufficient to claim reliable prevention.

Current guideline position

Class I/IIa in AHA/ASA 2022 ICH guidelines.

Clinical interpretation

INTERACT2, together with ATACH-2 and subsequent analyses, informed the later AHA/ASA recommendation to target about 140 mmHg and maintain 130–150 mmHg in selected mild-to-moderate spontaneous ICH, rather than establishing a universal 130–140 target.

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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