TRICH score predicts triple antihypertensive therapy need after ICH

A team from the LKS Faculty of Medicine at the University of Hong Kong (HKU) has developed an innovative clinical tool to help physicians effectively identify intracerebral haemorrhage (ICH) patients who would benefit from early initiation of triple antihypertensive therapy to reduce the risks of ICH recurrence and subsequent strokes.

“This [predictive tool] empowers doctors to give the right treatment at the right time,” noted Dr Kay-Cheong Teo of the Department of Medicine, HKU, a leader of the research team.

The TRICH score is derived from scoring five common clinical parameters: age, sex, history of ischaemic heart disease, kidney function (estimated glomerular filtration rate), and systolic blood pressure (BP) upon hospital admission. It aids prediction of the need for ≥3 antihypertensive medications at 3 months after ICH. [Neurology 2025;104:e213560] 

“As ICH survivors have high risks of recurrent ICH, stroke, and major adverse cardiac and cerebrovascular events [MACCE], especially in the first year after the index ICH, timely BP control is vital to reduce these risks,” the authors explained.

Use of the TRICH score also facilitates individualized treatment, mitigating the potential risk of overtreating patients who do not have severe underlying hypertension.  

The predictive five-item TRICH score was developed using data of 462 patients (mean age, 66.6 years; male, 60 percent) from the HKU stroke registry – an ongoing, prospective stroke registry that recruits consecutive patients with spontaneous ICH admitted to Queen Mary Hospital, Hong Kong. Patients enrolled in the registry from 2011 to 2022 were included in the development cohort.

The score developed was validated in another cohort of 203 consecutive patients with ICH (mean age, 66.3 years; male, 62 percent) who were admitted to three other hospitals in Hong Kong from 2020 to 2022: Ruttonjee Hospital, Yan Chai Hospital, and Princess Margaret Hospital. The ICH diagnosis was confirmed by CT scan of the brain. Patients aged ≥18 years with acute spontaneous ICH who survived beyond 90 days after the index event were included, while those with secondary ICHs (including ICH resulting from haemorrhagic cerebral infarct, head trauma, brain tumour, aneurysm, or vascular malformation) were excluded. The score had an acceptable discriminant value and performed better in patients with untreated/uncontrolled hypertension before ICH.

“Patients with a TRICH score of ≥3 should start a triple antihypertensive regimen within the first few days for prompt BP lowering, instead of gradual inpatient/outpatient titration of antihypertensive medications,” the authors recommended.

“Patients with poorly controlled hypertension face up to four times greater risk of ICH and stroke, which can lead to significant disability or death,” said Teo. “The TRICH score can guide clinicians to prescribe triple antihypertensive therapy early. Using combination antihypertensive pills is preferred to enhance drug compliance.”

Teo also highlighted the role of telemedicine in enhancing hypertension management. In addition to the TRICH score, HKU is pioneering the MOBILE-ICH (MOBILE Health Intervention in IntraCerebral Hemorrhage Survivors) study to investigate the safety and efficacy of telemedicine for managing hypertension in ICH patients.