Managing Hypertension in Patients With Acute Stroke

The Relation of End-Tidal CO 2 Values With Infarct Volume and Early Prognosis in Patients With Acute Ischemic Stroke

BACKGROUND

The aim of this study is to reveal the relationship between end-tidal CO 2 (EtCO 2 ) values with infarct volume and early prognosis in patients diagnosed with acute ischemic stroke in the emergency department.

MATERIALS AND METHODS

This prospective cross-sectional study was conducted in a tertiary hospital. The demographics, characteristics, EtCO 2 , volume of the stroke area on diffusion-weighted magnetic resonance imaging and the modified Rankin Scale (mRS) of the patients were recorded. The values calculated at admission and at discharge were labeled as "mRS-1" and "mRS-2," respectively, and the mRS-2 measurement was used as a prognostic indicator. The "good" and the "poor" functional outcomes were defined as mRS ≤2 and mRS >2, respectively. Correlations between levels of EtCO 2 and infarct volume, mRS were calculated.

RESULTS

In total, 44 patients were included in the study. The median age of the patients was 69 years (interquartile range; 16; min-max: 35 to 88 y) and 68.2% of them were male. In the univariate logistic regression models of the mRS-2 [0 to 2 (0) and 3 to 6 (1)], all variables were not statistically significant to predict mRS-2 group. There were statistically significant differences in EtCO 2 values between mRS-1 ( P =0.03) and mRS-2 ( P =0.04). A negative moderate correlation was found between EtCO 2 and mRS-2 ( r =-0.410; P =0.006). The correlation between EtCO 2 and infarct volume was not statistically significant ( r =-0.256; P =0.093).

CONCLUSIONS

This study highlights the importance of capnography follow-up of patients with acute ischemic stroke. In patients with acute ischemic stroke, the EtCO 2 value measured at the time of admission is lower in the group with high mRS at both admission and discharge.

Using Bayesian network model with MMHC algorithm to detect risk factors for stroke

Stroke is a major chronic non-communicable disease with high incidence, high mortality, and high recurrence. To comprehensively digest its risk factors and take some relevant measures to lower its prevalence is of great significance. This study aimed to employ Bayesian Network (BN) model with Max-Min Hill-Climbing (MMHC) algorithm to explore the risk factors for stroke. From April 2019 to November 2019, Shanxi Provincial People's Hospital conducted opportunistic screening for stroke in ten rural areas in Shanxi Province. First, we employed propensity score matching (PSM) for class balancing for stroke. Afterwards, we used Chi-square testing and Logistic regression model to conduct a preliminary analysis of risk factors for stroke. Statistically significant variables were incorporated into BN model construction. BN structure learning was achieved using MMHC algorithm, and its parameter learning was achieved with Maximum Likelihood Estimation. After PSM, 748 non-stroke cases and 748 stroke cases were included in this study. BN was built with 10 nodes and 12 directed edges. The results suggested that age, fasting plasma glucose, systolic blood pressure, and family history of stroke constitute direct risk factors for stroke, whereas sex, educational levels, high density lipoprotein cholesterol, diastolic blood pressure, and urinary albumin-to-creatinine ratio represent indirect risk factors for stroke. BN model with MMHC algorithm not only allows for a complicated network relationship between risk factors and stroke, but also could achieve stroke risk prediction through Bayesian reasoning, outshining traditional Logistic regression model. This study suggests that BN model boasts great prospects in risk factor detection for stroke.

Incident Stroke and Its Influencing Factors in Patients With Type 2 Diabetes Mellitus and/or Hypertension: A Prospective Cohort Study

Objective

To understand the incidence of stroke in patients with type 2 diabetes mellitus (T2DM) and/or hypertension (HTN), and provide a basis for the prevention of stroke in these patients.

Methods

A prospective cohort study was performed for adults with T2DM and/or HTN. The follow-up period was 1 year. The incidence and recurrence rate of stroke was calculated and a multivariate Cox proportional hazard was used to analyze influencing factors of stroke occurrence and recurrence in the follow-up of patients with T2DM and/or HTN.

Results

Of the 1,650 patients with T2DM and/or HTN, 1,213 patients had no history of stroke. After 1 year of follow-up, 147 new stroke cases occurred, and the incidence rate of stroke was 12.1%. Among the patients who had stroke history (413), there were 116 cases of stroke with a recurrence rate of 26.5%. Seven risk factors were independently associated with stroke occurrence among patients without stroke history, included smoking, abnormal total cholesterol abnormal low-density lipoprotein patients with comorbid T2DM with HTN, physical inactivity, carotid artery stenosis (CAS), and higher scores of National Institutes of Health Stroke Scale (NIHSS). Higher scores of NHISS and CAS were independent risk factors for the recurrence of stroke among patients with stroke history.

Conclusions

Patients with T2DM and/or HTN have a higher rate of new stroke and recurrence after 1-year follow-up. Actively identifying the controllable risk factors, such as smoking and physical inactivity, will help reduce the risk of stroke and recurrence in patients with T2DM and HTN.

ACEI/ARB Medication During ICU Stay Decrease All-Cause In-hospital Mortality in Critically Ill Patients With Hypertension: A Retrospective Cohort Study Based on Machine Learning

Background: Hypertension is a rather common comorbidity among critically ill patients and hospital mortality might be higher among critically ill patients with hypertension (SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg). This study aimed to explore the association between ACEI/ARB medication during ICU stay and all-cause in-hospital mortality in these patients.

Methods: A retrospective cohort study was conducted based on data from Medical Information Mart for Intensive Care IV (MIMIC-IV) database, which consisted of more than 40,000 patients in ICU between 2008 and 2019 at Beth Israel Deaconess Medical Center. Adults diagnosed with hypertension on admission and those had high blood pressure (SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg) during ICU stay were included. The primary outcome was all-cause in-hospital mortality. Patients were divided into ACEI/ARB treated and non-treated group during ICU stay. Propensity score matching (PSM) was used to adjust potential confounders. Nine machine learning models were developed and validated based on 37 clinical and laboratory features of all patients. The model with the best performance was selected based on area under the receiver operating characteristic curve (AUC) followed by 5-fold cross-validation. After hyperparameter optimization using Grid and random hyperparameter search, a final LightGBM model was developed, and Shapley Additive exPlanations (SHAP) values were calculated to evaluate feature importance of each feature. The features closely associated with hospital mortality were presented as significant features.

Results: A total of 15,352 patients were enrolled in this study, among whom 5,193 (33.8%) patients were treated with ACEI/ARB. A significantly lower all-cause in-hospital mortality was observed among patients treated with ACEI/ARB (3.9 vs. 12.7%) as well as a lower 28-day mortality (3.6 vs. 12.2%). The outcome remained consistent after propensity score matching. Among nine machine learning models, the LightGBM model had the highest AUC = 0.9935. The SHAP plot was employed to make the model interpretable based on LightGBM model after hyperparameter optimization, showing that ACEI/ARB use was among the top five significant features, which were associated with hospital mortality.

Conclusions: The use of ACEI/ARB in critically ill patients with hypertension during ICU stay is related to lower all-cause in-hospital mortality, which was independently associated with increased survival in a large and heterogeneous cohort of critically ill hypertensive patients with or without kidney dysfunction.

Current U.S. Guideline-Based Management Strategies for Special Clinical Situations Involving Hypertensive Crises: A Narrative Review of the Literature

Hypertensive crises, although somewhat rare in hypertensive patients, might become an increasingly relevant issue in the future as the number of adults living with hypertension in the United States increases. Many of the current U.S. clinical guidelines for the treatment and management of a variety of medical conditions do not factor hypertensive crises into their recommendations or only consider them in a limited fashion in the context of other medical conditions. This review article summarizes the definitions of hypertensive crises/urgent hypertension/emergent hypertension, the epidemiological profile and outcomes of patients, current U.S. clinical guidelines' recommendations for the general treatment of hypertensive crises, and current U.S. clinical guidelines' recommendations for the treatment of acute kidney injuries, acute ischemic stroke, aortic dissection, and acute heart failure in relation to hypertensive crises. All physicians who manage hypertensive patients, but particularly physicians who work in intensive care units, emergency departments and in U.S. hospitals, should review hypertensive crises guidelines and relevant treatments, and understand current recommendations.

Antihypertensive use for stroke in United States emergency departments

OBJECTIVE

Timely emergency department (ED) control of hypertension in the acute phase of stroke is associated with improved outcomes. It is unclear how emergency physicians use antihypertensive medications to treat severe hypertension associated with stroke. We sought to determine national patterns of antihypertensive use associated with ED visits for stroke in the United States.

METHODS

We analyzed data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) 2008-2017. We included ED visits associated with ischemic stroke (ICD9 433-434, ICD10 I630-I639) or hemorrhagic stroke (ICD9 430-432, ICD10 I600-I629). We estimated the number and proportions of stroke ED visits with triage blood pressure meeting treatment thresholds (triage systolic blood pressure [SBP] ≥180 mm Hg). We identified the frequency of antihypertensive use, as well as the most commonly used agents.

RESULTS

Between 2008-2017, of a total 135,012,819 ED visits, 619,791 were associated with stroke (78.3% ischemic strokes and 21.7% hemorrhage strokes). Of all stroke visits, 21.8% received antihypertensive medications. Of the identified visits, 9.0% (95% confidence interval [CI] = 6.0%, 13.1%) ischemic stroke visits and 58.2% (95% CI = 49.0%, 66.9%) hemorrhagic stroke visits met criteria for BP reduction. A total of 47.6% (95% CI = 29.1%, 66.7%) of eligible ischemic stroke visits and 41.5% (95% CI = 30.5%, 53.3%) of eligible hemorrhagic strokes visits received antihypertensives. The most common agents used in ischemic stroke were beta-blockers, calcium-channel blockers, and ACE inhibitors. The most common agents used in hemorrhagic stroke included calcium-channel blockers, beta-blockers, and vasodilators.

CONCLUSION

In this national sample, less than half of strokes presenting to the ED with hypertension received antihypertensive therapy.