Impact of Early Enteral Antihypertensive Initiation in Intracranial Hemorrhage

Introduction: Elevated blood pressure following spontaneous intracranial hemorrhage (ICH) can drive hematoma expansion and prolong intensive care unit (ICU) length of stay (LOS). Although intravenous (IV) nicardipine effectively controls blood pressure, its cost and intensive monitoring are limiting factors to its use. This study assessed whether transitioning from IV to enteral antihypertensives within 48 hours of admission can reduce ICU LOS without compromising patient safety, compared to a later transition.


Methods: Adults with spontaneous ICH who received at least one dose of enteral antihypertensive were stratified by time from admission to first enteral dose (early vs late). The primary endpoint was ICU LOS. Secondary safety and efficacy outcomes included hypotension, vasopressor use, change in National Institutes of Health Stroke Scale (NIHSS) ≥ 4 points, mortality, number of as-needed IV antihypertensive bolus doses, duration of IV nicardipine, and hospital LOS. Continuous data were analyzed with the Mann-Whitney U or t-test and categorical data with Fisher’s exact test.


Results: Eighty-three encounters met criteria (n=76 early group vs n=7 late group). More of the late transition patients were female (57% vs 16%, p = 0.023) and had higher median [IQR] NIHSS scores on admission (16 [10,21] vs 7 [2,15], p = 0.042). Other baseline characteristics were comparable. Median [IQR] ICU LOS was three days [2,6] in the early group and seven days [4,11] in the late group (p = 0.073). The early group required fever as-needed IV boluses of antihypertensive medications (6 [3,13] vs 13 [11,17], p = 0.042). Duration of IV nicardipine was similar between groups. Safety outcomes such as incidence of hypotension, vasopressor use, NIHSS at discharge, and in-hospital mortality did not differ between groups.


Conclusions: Initiating enteral antihypertensives within 48 hours of admission was associated with fewer as-needed IV antihypertensives boluses and similar safety outcomes. Larger studies are needed to confirm if an ICU LOS reduction can be attributed to earlier enteral antihypertensive administration.