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A Narrative Review of Cardiovascular Abnormalities After Spontaneous Intracerebral Hemorrhage

Lele, Abhijit, MBBS, MD, MS*; Lakireddy, Viharika, MBBS; Gorbachov, Sergii, MD, PhD; Chaikittisilpa, Nophanan, MD§; Krishnamoorthy, Vijay, MD, MPH*; Vavilala, Monica S., MD

Journal of Neurosurgical Anesthesiology: April 2019 - Volume 31 - Issue 2 - p 199–211
doi: 10.1097/ANA.0000000000000493
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Background: The recommended cardiac workup of patients with spontaneous intracerebral hemorrhage (ICH) includes an electrocardiogram (ECG) and cardiac troponin. However, abnormalities in other cardiovascular domains may occur. We reviewed the literature to examine the spectrum of observed cardiovascular abnormalities in patients with ICH.

Methods: A narrative review of cardiovascular abnormalities in ECG, cardiac biomarkers, echocardiogram, and hemodynamic domains was conducted on patients with ICH.

Results: We searched PubMed for articles using MeSH Terms “heart,” “cardiac,” hypertension,” “hypotension,” “blood pressure,” “electro,” “echocardio,” “troponin,” “beta natriuretic peptide,” “adverse events,” “arrhythmi,” “donor,” “ICH,” “intracerebral hemorrhage.” Using Covidence software, 670 articles were screened for title and abstracts, 482 articles for full-text review, and 310 extracted. A total of 161 articles met inclusion and exclusion criteria, and, included in the manuscript. Cardiovascular abnormalities reported after ICH include electrocardiographic abnormalities (56% to 81%) in form of prolonged QT interval (19% to 67%), and ST-T changes (19% to 41%), elevation in cardiac troponin (>0.04 ng/mL), and beta-natriuretic peptide (BNP) (>156.6 pg/mL, up to 78%), echocardiographic abnormalities in form of regional wall motion abnormalities (14%) and reduced ejection fraction. Location and volume of ICH affect the prevalence of cardiovascular abnormalities. Prolonged QT interval, elevated troponin-I, and BNP associated with increased in-hospital mortality after ICH. Blood pressure control after ICH aims to preserve cerebral perfusion pressure and maintain systolic blood pressure between 140 and 179 mm Hg, and avoid intensive blood pressure reduction (110 to 140 mm Hg). The recipients of ICH donor hearts especially those with reduced ejection fraction experience increased early mortality and graft rejection.

Conclusions: Various cardiovascular abnormalities are common after spontaneous ICH. The workup of patients with spontaneous ICH should involve 12-lead ECG, cardiac troponin-I, as well as BNP, and echocardiogram to evaluate for heart failure. Blood pressure control with preservation of cerebral perfusion pressure is a cornerstone of hemodynamic management after ICH. The perioperative implications of hemodynamic perturbations after ICH warrant urgent further examination.

*Department of Anesthesiology

Department of Anesthesiology, Neuroanesthesiology Division, Harborview Medical Center, University of Washington

Department of Anesthesiology, Harborview Medical Center, Harborview Injury Prevention and Research Center, University of Washington

Harborview Injury Prevention and Research Center, Seattle, WA

§Siriraj Hospital, Mahidol University, Bangkok, Thailand

A.L. has received research support from Edge Therapeutics for NEWTON-2 study, Aqueduct Critical Care for the ASSESSED clinical trial, and from NIH/NINDS for the ATACH-II clinical trial, none of which are relevant to this study. The remaining authors have no funding or conflicts of interest to disclose.

Address correspondence to: Abhijit Lele, MBBS, MD, MS, Department of Anesthesiology, Harborview Medical Center, University of Washington, 325, 9th Avenue, P.O. Box 356540, Seattle, WA 98104 (e-mail: abhijit2@uw.edu).

Received October 17, 2017

Accepted December 31, 2017

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