Ambulatory blood pressure variability within the first 24 hours after admission and outcomes of acute ischemic stroke

Relationship of Day-by-Day Blood Pressure Variability and Admission Stroke Severity in Acute Ischemic Stroke

OBJECTIVES

Research on the association between stroke severity and day-by-day blood pressure variability (BPV) in acute ischemic stroke (AIS) is rare as the majority focus on the blood pressure (BP) or the short-term BPV. Our study aims to explore the exact roles of daily BPV through the 7-day commencement on stroke severity in AIS.

METHODS

The study included 633 patients with AIS, defining AIS as the time from the beginning of symptom up to 7 days with recording BP twice a day as well as calculating the daily BPV, and then matching them to the stroke severity. The logistic regression models were used to evaluate associations between stroke severity and day-by-day BPV. We used the smooth curve fitting to identify whether there was a nonlinear association. In addition, the subgroup analyses were performed using the logistic regression.

RESULTS

According to the modified National Institutes of Health Stroke Scale score, 301 (47.5%) patients were allocated to the mild stroke group and 332 (52.5%) to the moderate-to-severe stroke group. In terms of stroke categories, we found no significant difference between BP at admission or mean BP. However, the moderate-to-severe stroke group exhibited higher daily BPV. The multiple logistic regression analysis indicated that day-by-day BPV was positively correlated to stroke severity [odds ratio (OR)=1.05, 95% CI:1.01-1.1, P =0.03 for SBP-SD; OR=1.08, 95% CI:1.01-1.15, P =0.03 for SBP-CV; OR=1.04, 95% CI:1.01-1.07, P =0.015 for SBP-SV).

CONCLUSIONS

High day-by-day BPV in AIS was associated with more severe stroke independent of BP levels.

Daily blood pressure variability in relation to neurological functional outcomes after acute ischemic stroke

Background

Prior research has shown inconclusive findings regarding the relationship between blood pressure variability (BPV) in acute ischemic stroke (AIS) and functional outcomes. Most research has examined the connection between short-term BPV during the early 24-72 h after the occurrence of ischemic stroke and functional prognosis. We sought to determine the relationship between daily BPV at 7 days of commencement and functional outcomes during the 3 months following AIS.

Methods

Altogether, 633 patients with AIS admitted within 72 h of commencement were enrolled. AIS was defined as the time from the onset of symptoms to 7 days. Throughout this period, blood pressure (BP) was recorded twice daily (casual BP cuffs). The daily BPV, with standard deviation (SD) and coefficient of variation (CV), was calculated and matched to the functional results. The adverse outcome was characterized as a modified Rankin scale (mRS)≥3, which comprised the recurrence of stroke, clinical intracranial bleeding, and death.

Results

In total, 633 participants were included, and the incidence of adverse outcomes was 14.06% (89/633). There was a significant positive correlation between daily BPV and adverse outcomes but not between mean BP and risk. Smooth curve fitting revealed a U-shaped connection between the mean BP and adverse clinical outcomes. Multivariable logistic regression analysis showed an independent correlation between daily BPV and an adverse outcome in the top vs. bottom quartile of systolic BPV (odds ratio [OR] = 2.4, 95% confidence interval [CI]: 1.17-4.96, P = 0.018 for SD; OR = 2.4, 95% CI: 1.17-4.93, P = 0.017 for CV) during a 3-month follow-up period. Identical results have been reported for diastolic BPV.

Conclusion

Irrespective of BP level, elevated daily systolic BPV and diastolic BPV in AIS were associated with an increased risk of adverse outcomes within 3 months. We also discovered a U-shaped association between the mean BP and adverse clinical outcomes. These findings suggested that BPV should be a risk factor for adverse outcomes after ischemic stroke, which provided new insight into BP management strategy.

Systolic blood pressure trajectories after acute ischemic strokes and clinical outcomes: A systematic review

Blood pressure(BP) varies drastically during the acute phase after stroke onset. BP level and BP variability may have a major impact on acute ischemic stroke (AIS) prognosis. However, the association between trajectories of blood pressure over time and clinical outcomes have not been established. This review sought out existing evidences for associations of systolic blood pressure (SBP) trajectories on outcomes after stroke to determine the connection between SBP trajectories and stroke prognosis. According to a pre‐designed search strategy, literature search was carried out in Embase, Pubmed and Web of Science. Two authors independently evaluated study eligibility and quality, and literature data were extracted. When the literature was eligible, we perform meta‐analysis to determine associations of SBP trajectories with clinical outcomes. Seven studies were finally screened out of 52 studies retrieved. Seven studies received a good risk of bias rating and reported BP measurement methods and intervals, BP trajectories modeling methods, outcome measures, but it was found that final systolic BP trajectories in various papers were significantly different. All studies reported statistically significant associations between systolic blood pressure trajectories and prognosis. Methodological heterogeneity is observed in studies. However, this systematic review suggests that the high SBP group after AIS is related to poor clinical outcomes, while the rapid decline or medium‐to‐low or low SBP group is associated with relatively better clinical outcomes at different period after stroke. More prospective studies are needed to report the full methodology according to standardized criteria and explore relationships between SBP trajectories and prognosis of stroke.

Day-by-Day Blood Pressure Variability in the Subacute Stage of Ischemic Stroke and Long-Term Recurrence

BACKGROUND AND PURPOSE

This study aimed to determine whether variability of day-by-day blood pressure (BP) during the subacute stage of acute ischemic stroke is predictive of long-term stroke recurrence.

METHODS

We analyzed 7665 patients (mean±SD age: 72.9±13.1 years; women: 42.4%) hospitalized for first-ever ischemic stroke in 7 stroke centers in Fukuoka, Japan, from June 2007 to November 2018. BP was measured daily during the subacute stage (4-10 days after onset). Its mean and coefficient of variation (CV) values were calculated and divided into 4 groups according to the quartiles of these BP parameters. Patients were prospectively followed up for recurrent stroke or all-cause death. The cumulative event rate was calculated with the Kaplan-Meier method. We estimated the hazard ratios and 95% confidence intervals of the events of interest after adjusting for potential confounders and mean BP values using Cox proportional hazards models. The Fine-Gray model was also used to account for the competing risk of death.

RESULTS

With a mean (±SD) follow-up duration of 3.9±3.2 years, the rates of recurrent stroke and all-cause death were 3.9 and 9.9 per 100 patient-years, respectively. The cumulative event rates of recurrent stroke and all-cause death increased with increasing CVs of systolic BP and diastolic BP. The systolic BP CV was significantly associated with an increased risk of recurrent stroke after adjusting for multiple confounders and mean BP (hazard ratio [95% CI] for fourth quartile versus first quartile, 1.26 [1.05-1.50]); the risk of recurrent stroke also increased with an increasing systolic BP CV for nonfatal strokes (1.26 [1.05-1.51]) and when death was regarded as a competing risk (1.21 [1.02-1.45]). Similar associations were observed for the diastolic BP CV.

CONCLUSIONS

Day-by-day variability of BP during the subacute stage of acute ischemic stroke was associated with an increased long-term risk of recurrent stroke.

Increased Pulse Pressure Variability Within the First 24 Hours Leads to Poor Disposition in Subarachnoid Hemorrhage Patients

BACKGROUND

Aneurysmal subarachnoid hemorrhage (SAH) continues to be associated with significant morbidity and mortality despite treatment advancements. Although high blood pressure (BP) remains a significant risk factor in aneurysmal SAH and rerupture, the role of BP parameters and fluctuation in prognostication remains unclear. We sought to define how BP parameters and variability within 24 hours of hospitalization in acute-onset SAH affects patient discharge outcomes.

METHODS

We retrospectively analyzed a prospectively collected cohort of SAH patients. Hourly BP parameters, including systolic BP (SBP), diastolic BP, pulse pressure (PP), and their corresponding variability (delineated by SD), were collected to investigate associations with the primary endpoint of discharge disposition.

RESULTS

One hundred and seventy-four SAH patients were included in the study. On bivariate analysis, Hunt-Hess (HH) score, Fisher grade, intraventricular hemorrhage, external ventricular drain placement, and SBP and PP variability were significantly associated with a poor disposition. Poor disposition was significantly associated with age, HH score, intraventricular hemorrhage, and PP variability on multivariate analysis. PP variability remained an independent predictor for poor disposition (odds ratio 1.11, 95% confidence interval, 1.02-1.21, P = 0.02) when adjusting for potential confounders.

CONCLUSIONS

Increased BP and PP variability within the first 24 hours of admission portends a poor discharge disposition for aneurysmal SAH patients.

Association Between Blood Pressure Variability and Short-Term Outcome After Intra-arterial Thrombectomy in Acute Stroke Patients With Large-Vessel Occlusion

The optimal range of blood pressure variability (BPV) for acute stroke patients with large-vessel occlusion (LVO) remains unclear. This study investigated the association between BPV from admission through the first 24 h after intra-arterial thrombectomy (IAT) and short-term outcome in LVO patients. We retrospectively analyzed 257 consecutive patients with LVO stroke who were treated with IAT. BP values were recorded at 2-h intervals from admission through the first 24 h after IAT. BPV, as reflected by pulse pressure variability (PPV), was determined based on standard deviation (SD), coefficient of variation (CV), successive variation (SV), and the difference between maximum and minimum blood pressure (ΔBP; systolic BP minus diastolic BP). The association between BPV and clinical outcome (Modified Rankin Scale score at 90 days) was analyzed by multivariate logistic regression analysis. Of the 257 included patients, 70 had a good outcome at 3 months. PPV from admission through the first 24 h after IAT was independently associated in a graded manner with poor outcome [multivariable-adjusted odds ratios (95% confidence interval) for the highest of PPV were 43.0 (8.7–212.8) for SD, 40.3 (9.8–165.0) for CV, 55.0 (11.2–271.2) for SV, and 40.1 (8.0–201.9) for ΔBP]. The area under the receiver operating characteristic curve (95% confidence interval) of the PPV parameters were 0.924 (0.882–0.965) for SD, 0.886 (0.835–0.938) for CV, 0.932 (0.891–0.973) for SV, and 0.892 (0.845–0.939) for ΔBP, and the Youden index values were 0.740, 0.633, 0.759, and 0.756, respectively. In summary, BPV from admission through the first 24 h after IAT was independently associated with poor outcome at 3 months in patients with LVO, with greater variability corresponding to a stronger association. Thus, PPV may be a clinically useful predictor of functional prognosis in LVO patients treated with IAT.

Day-by-Day Blood Pressure Variability Is Associated With Neurological Functional Outcome After Acute Ischemic Stroke

Background: Increased blood pressure variability (BPV) might be a detrimental factor after acute ischemic stroke. Previous studies on the association between blood pressure variability in the acute ischemic stroke and functional outcome have yielded inconsistent results. We aimed to investigate the impact of day-by-day blood pressure variability within 7 days of onset on functional outcome at 3 months after acute ischemic stroke.

Methods: Total 367 patients hospitalized for ischemic stroke within 48 h of onset were enrolled. The acute stage of ischemic stroke was defined as the time period from symptom onset to 7 days. During this period, blood pressure was measured twice daily (respectively, in the morning during 8:00 a.m.−10:00 a.m., in the afternoon between 15:00 p.m. and 17:00 p.m.). Day-by-day blood pressure variability, including standard deviation (SD) and coefficient variation (CV) were derived and compared to functional outcome. We dichotomized function outcome according to mRS score and unfavorable outcome was defined as mRS ≥3.

Results: The patients with unfavorable outcome had significantly higher systolic BPV (within 7 days of onset) than those with favorable outcome (15.41 ± 4.59 vs. 13.42 ± 3.95 mmHg for SD, P < 0.001; 11.54 ± 3.23 vs. 10.41 ± 2.82 for CV, P = 0.001). Multivariable logistic regression analysis revealed that systolic BPV was significantly and independently associated with the 3-month functional outcome [odds ratio (OR) = 1.15, 95% confidence interval (CI): 1.07–1.22, P < 0.001 for SD; OR = 1.15, 95% CI: 1.06–1.26, P = 0.001 for CV]. In addition, After adjustment for multiple confounding factors, including age, gender, risk factors, stroke features, baseline severity, recanalized therapy, hemorrhagic transformation, pulmonary infection, white blood cell, estimated Glomerular Filtration Rate and mean BP, day-by-day BP variability was significantly correlated with an unfavorable outcome in the top vs. bottom quartile of systolic BPV (OR = 3.33, 95% CI: 1.41–7.85, P = 0.006 for SD; OR = 2.27, 95% CI: 1.04–4.94, P = 0.037 for CV) during 3-month follow-up. Similar trends were also observed for diastolic BPV. More importantly, incorporating SD of systolic BP into the conventional prediction model could significantly increase the AUC for prediction of 3-month unfavorable outcome after acute ischemic stroke (0.84 vs. 0.86; P = 0.0416).

Conclusions: Increased day-by-day blood pressure variability of systolic or diastolic BP in the acute ischemic stroke was associated with higher risk for unfavorable outcome at 3 months independent of blood pressure levels. Combining SD of systolic BP with conventional risk factors could improve the prediction of unfavorable outcome.

Combined prognostic significance of D-dimer level and platelet count in acute ischemic stroke

BACKGROUND

D-dimer level and platelet count (PC) have been reported separately as significant independent predictors of Acute Ischemic Stroke (AIS). Here, we aimed to investigate the combined prognostic value of abnormal D-dimer level and PC as defined for specific in-hospital and long-term outcomes in AIS patients.

METHODS

A total of 1468 patients admitted for ischemic stroke within 24 h of symptom onset from April 1, 2016 to November 31, 2019 at the Department of Neurology, the First Affiliated Hospital of Harbin Medical University were included in the final analysis. Eligible subjects were divided into four groups in terms of their levels of D-dimer and PC: DD-PC- (normal D-dimer level and normal PC), DD-PC+ (normal D-dimer level and abnormal PC), DD+PC- (higher D-dimer level and normal PC), and DD+PC+ (higher D-dimer level and abnormal PC). Logistic regression model and multinomial logit model were used to estimate the combined effect of D-dimer level and PC on in-hospital outcomes including discharge outcome and early neurological changes, and poor outcomes at 3, 6 and 12 months.

RESULTS

DD+PC+ was found to be associated with the risk of in-hospital mortality (adjusted odds ratio [OR], 6.904; 95% confidence interval [CI], 2.781-17.144) and 3-month mortality (adjusted OR, 5.455; 95% CI, 2.019-14.743) compared with DD-PC-. Combination of the two indicators significantly improved the independent predictive value for functional outcomes, including early neurological deterioration (END) (OR, 3.622; 95% CI, 1.732-7.573) with threshold of at least 4-point increase on NIHSS, discharge outcome (OR, 2.713; 95% CI, 1.421-5.177); mRS of 0-1 point (OR, 0.409; 95% CI, 0.211-0.792), mRS of 0-2 points (OR, 0.234; 95% CI, 0.118, 0.461), and higher mRS-shift (OR, 2.379; 95% CI, 1.237-4.576) at 3 months; unfavorable outcome at 3 months (OR, 4.280; 95% CI, 2.169-8.446), 6 months (OR, 3.297; 95% CI, 1.452-7.488) and 12 months (OR, 4.157; 95% CI, 1.598-10.816). While comparatively weaker statistical significance was shown in DD+PC- and no correlation was found between adverse outcomes and DD-PC+. Similarly, patients with abnormal D-dimer level and PC were less likely to reach the status of stable or improving.

CONCLUSIONS

Combination of D-dimer level and PC may have more significant prognostic value on END, in-hospital mortality, discharge outcome, and long-term outcomes than either index of D-dimer level or PC alone in AIS patients.

Blood pressure variability and outcome in acute ischemic and hemorrhagic stroke: a post hoc analysis of the HeadPoST study

The Head Positioning in Acute Stroke Trial (HeadPoST) is a pragmatic, international, cluster crossover randomized trial of 11,093 patients with acute stroke assigned to a lying-flat (0°) or sitting-up (head elevated ≥30°) position. This post-hoc analysis aimed to determine the association between BPV and outcomes for patients from a wide range of international clinical settings and how the association was modified by randomized head position. BPV was defined according to standard criteria with the key parameter considered the coefficient of variation (CV) of systolic BP (SBP) over 24 hours. Outcome was ordinal 90-day modified Rankin Scale (mRS) score. The association was analyzed by ordinal, logistic regression, hierarchical, mixed models with fixed intervention (lying-flat vs. sitting-up), and fixed period, random cluster, and random cluster-period, effects. 9,156 (8,324 AIS and 817 ICH; mean age 68.1 years; 39.2% women) were included in the analysis. CV of SBP had a significant linear association with unfavorable shift of mRS at 90 days (adjusted odds ratio [OR] 1.06, 95% confidence interval [CI] 1.02-1.11; P=0.01). There was no heterogeneity of the association by randomized head positioning. In addition, CV of diastolic BP (DBP) (1.08, 1.03-1.12; P=0.001) over 24 hours post stroke, was significantly associated with 3-month poor outcome. The association was more apparent in sitting-up position (1.12, 1.06-1.19) compared with lying-flat position (1.03, 0.98-1.09) (P interaction = 0.005). BPV was associated with adverse stroke outcome, the magnitude of the association was greater with sitting-up head positioning in terms of DBP variability.

Increased blood pressure variability following acute stroke is associated with poor long-term outcomes: a systematic review

BACKGROUND

Blood pressure variability (BPV) in acute ischemic stroke (AIS) may be of prognostic significance. However, methodological heterogeneity of studies may contribute to inconsistent findings, and study findings are therefore not readily comparable. We investigated study methodologies which have assessed the long-term outcomes (≥7 days) of BPV post-AIS.

MATERIALS AND METHODS

The literature search was conducted in OVID Medline, Embase, The Cochrane Library, and Web of Science following a predefined search strategy. Two reviewers independently assessed study eligibility and quality, and source data were extracted.

RESULTS

Of 2044 studies identified, 19 observational studies and one case-control study were included; seven studies were additionally included. Twenty-two studies obtained good risk of bias ratings. Key findings were methodological heterogeneity and significant variability in the reporting of key criteria. Twenty-four studies reported intervals between blood pressure assessments; although 19 studies reported the monitoring device used, only eight studies reported the number of blood pressure measurements taken per visit. The majority measured supine blood pressure (n=13), and eight studies reported whether this was in the hemiparetic or unaffected arm. Sixteen studies defined BPV using SD and seven studies used only a single blood pressure parameter to quantify BPV. Increased BPV was associated with poorer neurological and functional outcomes, and death (n=23); other unfavorable outcomes included irregularly shaped lacunar infarcts, and impaired cognition (n=3).

CONCLUSION

Methodological heterogeneity is frequently observed in studies, primarily because of incomplete study reporting. However, increased BPV is associated with adverse long-term outcomes. There is a need for prospective studies investigating BPV post-AIS to report full methodologies according to standardized criteria.