A daily combination pill containing three medications for high blood pressure reduces the risk of a recurrent brain hemorrhage in patients who have previously experienced such a bleed. In addition, patients experience fewer side effects because the pill contains lower doses of medication. This is shown by a large international study involving, among others, Radboudumc. The results have now been published in the New England Journal of Medicine.
The study shows that patients who took a so-called triple pill had a 39% lower risk of a recurrent stroke than patients who received a placebo. Among those using this medication, blood pressure was on average nine points lower. They also developed severe cardiovascular disease less frequently. The study followed participants for more than seven years; never has research of this scale been conducted on treatments aimed at preventing recurrent strokes after brain hemorrhage.
Vulnerable patients
Each year, approximately eight to nine thousand people in the Netherlands suffer a brain hemorrhage, often with major and lasting consequences. ‘Worldwide, about one third of people with a brain hemorrhage die within a month. Of those who survive, half remain dependent on care,’ says Karin Klijn, Professor of Neurology and specialist in brain hemorrhages. This makes them a particularly vulnerable group of patients. They also face an increased risk of a recurrent hemorrhage, in which a blood vessel in the brain ruptures, or an ischemic stroke, in which a blood vessel is blocked by a blood clot.
High blood pressure is a well-known risk factor for brain hemorrhage, Klijn explains. This is challenging, because high blood pressure is not always recognized in time. ‘People can live with it for a long time without clear symptoms. We did not know whether blood pressure control after a brain hemorrhage should be more intensive to reduce the risk of a new stroke.’
One pill a day
This study now shows that lowering blood pressure reduces the risk of a recurrent stroke, mainly by decreasing the likelihood of another brain hemorrhage. Moreover, this new treatment, combining three different blood pressure–lowering medications in low doses into a single pill, is attractive for patients. ‘They only need to take one pill a day. Because the doses are low, people experience fewer side effects. This increases adherence to treatment,’ Klijn explains. The message is clear: lower blood pressure helps prevent recurrent brain hemorrhages.
Making a difference
Hospitals from ten different countries participated in this large-scale study. In the Netherlands, Radboudumc enrolled the largest number of participants. Neurologist Floris Schreuder, who supervised many of them, explains: ‘For years, we had few concrete options to truly reduce the risk of recurrent bleeding in these patients. With this study, we show that a simple, well-tolerated treatment can genuinely make a difference in the daily lives and future of people after a brain hemorrhage.’
Although the combination pill used in the study is not yet available in the Netherlands, the three individual medications are already available separately, allowing physicians to apply the low-dose strategy immediately. Meanwhile, further consideration is being given to how this combination pill can be implemented in the Netherlands. Klijn also expects these new insights to lead to adjustments in both national and international treatment guidelines. ‘With this large-scale international collaboration, we have laid a solid foundation for that.’
About the publication
This research was published in New England Journal of Medicine: Three Low-Dose Antihypertensive Agents in a Single Pill after Intracerebral Hemorrhage. Craig Anderson, Clara Chow, […], Karin Klijn, […], Floris Schreuder, […], John Chalmers, Anthony Rodgers. DOI: 10.1056/NEJMoa2515043.
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