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Chen Y, Ma Y, Qin J, Wei X, Yang Y, Yuan Y, Yan F, Huo X, Han L. Blood pressure variability predicts poor outcomes in acute stroke patients without thrombolysis: a systematic review and meta-analysis. J Neurol 2024; 271:1160-1169. [PMID: 38036920 DOI: 10.1007/s00415-023-12054-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 10/07/2023] [Accepted: 10/09/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Stroke is a significant medical condition, and blood pressure stands out as the most prevalent treatable risk factor associated with it. Researches link blood pressure variability (BPV) with stroke; however, the specific relationship between with the outcomes of stroke patients remains unclear. As blood pressure variability and mean blood pressure are interrelated, it remains uncertain whether BPV adds additional information to understanding the outcome of acute stroke patients. OBJECTIVE To systematically review studies investigating the association between blood pressure variability and prognosis in acute stroke patients. METHODS Embase, PubMed, Web of Science, and the Cochrane Library were searched for English language full-text articles from the inception to 1 January 2023. Stroke patients aged ≥ 18 years were included in this analysis. Stroke types were not restricted. RESULTS This meta-analysis shows that higher systolic blood pressure variability is linked to a higher risk of poor outcome, including function disability, mortality, early neurological deterioration, and stroke recurrence, among acute stroke patients without thrombolysis. A higher diastolic blood pressure variability is linked with to a higher risk of mortality and functional disability. CONCLUSIONS This review reveals that blood pressure variability is a novel and clinically relevant risk factor for stroke patients' outcome. Future studies should investigate how best to measure and define BPV in acute stroke. Larger studies are warranted to provide more robust evidence in this area.
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Affiliation(s)
- Yajing Chen
- Evidence-Based Nursing Centre, School of Nursing, Lanzhou University, Lanzhou, Gansu Province, China
| | - Yuxia Ma
- Evidence-Based Nursing Centre, School of Nursing, Lanzhou University, Lanzhou, Gansu Province, China.
- The First Clinical Medical College of Lanzhou University, Lanzhou, 730030, Gansu Province, China.
| | - Jiangxia Qin
- Evidence-Based Nursing Centre, School of Nursing, Lanzhou University, Lanzhou, Gansu Province, China
| | - Xiaoqin Wei
- Evidence-Based Nursing Centre, School of Nursing, Lanzhou University, Lanzhou, Gansu Province, China
| | - Yiyi Yang
- Evidence-Based Nursing Centre, School of Nursing, Lanzhou University, Lanzhou, Gansu Province, China
| | - Yue Yuan
- Evidence-Based Nursing Centre, School of Nursing, Lanzhou University, Lanzhou, Gansu Province, China
| | - Fanghong Yan
- Evidence-Based Nursing Centre, School of Nursing, Lanzhou University, Lanzhou, Gansu Province, China
| | - Xiaoning Huo
- The Third People's Hospital of Lanzhou, No.130 Jianlan New Village, Lanzhou, Gansu Province, China
| | - Lin Han
- Evidence-Based Nursing Centre, School of Nursing, Lanzhou University, Lanzhou, Gansu Province, China.
- Department of Nursing, Gansu Provincial Hospital, No. 204 Donggang West Road, Lanzhou, Gansu Province, China.
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Nazar E, Esmaily H, Yousefi R, Jamali J, Ghandehari K, Hashtarkhani S, Jafari Z, Shakeri MT. A Spatial Variation Analysis of In-Hospital Stroke Mortality Based on Integrated Pre-Hospital and Hospital Data in Mashhad, Iran. ARCHIVES OF IRANIAN MEDICINE 2023; 26:300-309. [PMID: 38310430 PMCID: PMC10685828 DOI: 10.34172/aim.2023.46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 05/01/2022] [Indexed: 02/05/2024]
Abstract
BACKGROUND Despite significant advances in the quality and delivery of specialized stroke care, there still persist remarkable spatial variations in emergency medical services (EMS) transport delays, stroke incidence, and its outcomes. Therefore, it is very important to investigate the possible geographical variations of in-hospital stroke mortality and to identify its associated factors. METHODS This historical cohort study included suspected stroke cases transferred to Ghaem Hospital of Mashhad by the EMS from March 2018 to March 2019. Using emergency mission IDs, the pre-hospital emergency data were integrated with the patient medical records in the hospital. We used the Bayesian approach for estimating the model parameters. RESULTS Out of 301 patients (142 (47.2%) females vs. 159 (52.8%) males) with a final diagnosis of stroke, 61 (20.3%) cases had in-hospital mortality. Results from Bayesian spatial log-logistic proportional odds (PO) model showed that age (PO=1.07), access rate to EMS (PO=0.78), arrival time (evening shift vs. day shift, PO=0.09), and sequelae variables (PO=9.20) had a significant association with the odds of in-hospital stroke mortality (P<0.05). Furthermore, the odds of in-hospital stroke mortality were higher in central urban areas compared to suburban areas. CONCLUSION Marked regional variations were found in the odds of in-hospital stroke mortality in Mashhad. There was a direct association between age and odds of in-hospital stroke mortality. Hence, the prognosis of in-hospital stroke mortality could be improved by better control of hypertension, prevention of the occurrence of sequelae, increasing the access rate to EMS, and optimizing shift work schedule.
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Affiliation(s)
- Eisa Nazar
- Psychiatry and Behavioral Sciences Research Center, Addiction Institute, Mazandaran University of Medical Sciences, Mazandaran, Iran
- Orthopedic Research Center, Mazandaran University of Medical Sciences, Sari, Iran
| | - Habibollah Esmaily
- Department of Biostatistics, School of Public Health, Social Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Razieh Yousefi
- Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Biostatistics, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Jamshid Jamali
- Department of Biostatistics, School of Public Health, Social Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Kavian Ghandehari
- Neurocognitive Research Center, Department of Neurology, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Soheil Hashtarkhani
- Center for Biomedical Informatics, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, USA
| | - Zahra Jafari
- Clinical Research Development Unit, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Taghi Shakeri
- Department of Biostatistics, School of Public Health, Social Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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Ouyang M, Muñoz-Venturelli P, Billot L, Wang X, Song L, Arima H, Lavados PM, Hackett ML, Olavarría VV, Brunser A, Middleton S, Pontes-Neto OM, Lee TH, Watkins CL, Robinson T, Anderson CS. Low blood pressure and adverse outcomes in acute stroke: HeadPoST study explanations. J Hypertens 2021; 39:273-279. [PMID: 32897905 PMCID: PMC7810418 DOI: 10.1097/hjh.0000000000002649] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/13/2020] [Accepted: 08/15/2020] [Indexed: 01/14/2023]
Abstract
OBJECTIVE As uncertainties exist over underlying causes, we aimed to define the characteristics and prognostic significance of low blood pressure (BP) early after the onset of acute stroke. METHODS Post hoc analyzes of the international Head Positioning in acute Stroke Trial (HeadPoST), a pragmatic cluster-crossover randomized trial of lying flat versus sitting up in stroke patients from nine countries during 2015-2016. Associations of baseline BP and death or dependency [modified Rankin scale (mRS) scores 3-6] and serious adverse events (SAEs) at 90 days were assessed in generalized linear mixed models with adjustment for multiple confounders. SBP and DBP was analysed as continuous measures fitted with a cubic spline, and as categorical measures with low (<10th percentile) and high (≥140 and ≥90 mmHg, respectively) levels compared with a normal range (≥10th percentile; 120-139 and 70-89 mmHg, respectively). RESULTS Among 11 083 patients (mean age 68 years, 39.9% women) with baseline BP values, 7.2 and 11.7% had low SBP (<120 mmHg) and DBP (<70 mmHg), respectively. Patients with low SBP were more likely to have preexisting cardiac and ischemic stroke and functional impairment, and to present earlier with more severe neurological impairment than other patients. Nonlinear 'J-shaped' relationships of BP and poor outcome were apparent: compared with normal SBP, those with low SBP had worse functional outcome (adjusted odds ratio 1.27, 95% confidence interval 1.02-1.58) and more SAEs, particularly cardiac events, with adjustment for potential confounders to minimize reverse causation. The findings were consistent for DBP and were stronger for ischemic rather than hemorrhagic stroke. CONCLUSION The prognostic significance of low BP on poor outcomes in acute stroke was not explained by reverse causality from preexisting cardiovascular disease, and propensity towards greater neurological deficits and cardiac events. These findings provide support for the hypothesis that low BP exacerbates cardiac and cerebral ischemia in acute ischemic stroke.
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Affiliation(s)
- Menglu Ouyang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
- The George Institute China at Peking University Health Science Center, Beijing, China
| | - Paula Muñoz-Venturelli
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
- Centro de Estudios Clínicos, Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina Clínica Alemana Universidad del Desarrollo
- Unidad de Neurología Vascular, Servicio de Neurología, Departmento de Neurología and Psiquiatría, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Laurent Billot
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Xia Wang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Lili Song
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
- The George Institute China at Peking University Health Science Center, Beijing, China
| | - Hisatomi Arima
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Pablo M. Lavados
- Unidad de Neurología Vascular, Servicio de Neurología, Departmento de Neurología and Psiquiatría, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Maree L. Hackett
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, Lancashire, UK
| | - Verónica V. Olavarría
- Unidad de Neurología Vascular, Servicio de Neurología, Departmento de Neurología and Psiquiatría, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Alejandro Brunser
- Unidad de Neurología Vascular, Servicio de Neurología, Departmento de Neurología and Psiquiatría, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne and Australian Catholic University, Sydney, Australia
| | - Octavio M. Pontes-Neto
- Stroke Service - Neurology Division, Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of Sao Paulo, Ribeirão Preto – SP, Brazil
| | - Tsong-Hai Lee
- Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Caroline L. Watkins
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, Lancashire, UK
| | - Thompson Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Craig S. Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
- The George Institute China at Peking University Health Science Center, Beijing, China
- Centro de Estudios Clínicos, Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina Clínica Alemana Universidad del Desarrollo
- Neurology Department, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, Australia
- Heart Health Research Center, Beijing, China
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Ajinkya S, Almallouhi E, Turner N, Al Kasab S, Holmstedt CA. The Relationship Between Admission Systolic Blood Pressure and Mortality in Telestroke Patients. Telemed J E Health 2019; 26:941-944. [PMID: 31600113 DOI: 10.1089/tmj.2019.0151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: A "U-shaped" relationship between admission blood pressure (BP) and mortality (wherein patients within a middle range have better outcomes than patients at higher or lower extremes) in patients receiving intravenous recombinant tissue-plasminogen activator (tPA) has been previously described. We aim to determine if this U-shaped relationship persists for patients in a telestroke setting regardless of tPA administration. Materials and Methods: We conducted a retrospective chart review of the prospectively collected registry data for all patients seen through the Medical University of South Carolina (MUSC) telestroke network. Admission systolic BP (SBP) was divided into quartiles with thresholds based on the 25th, 50th, and 75th percentiles as cut points separately by tPA status. The primary outcomes of this study were odds of 90-day modified Rankin scale ≤2 and 90-day mortality. Logistic regression analyses were used to analyze associations between BP quartiles and these outcomes, adjusted for relevant clinical covariates. Results: Our sample comprised 1,232 patients evaluated for telestroke, 616 of whom received tPA. Patients in the second (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.15-0.77 in the tPA group, OR 0.27, 95% CI 01.0-0.78 in the non-tPA group) and third (OR 0.26, 95% CI 0.11-0.64 in the tPA group, OR 0.36, 95% CI 0.14-0.92 in the non-tPA group) quartiles of admission SBP had lower adjusted odds of 90-day mortality. Conclusions: Our findings support a U-shaped relationship between admission SBP and 90-day mortality in acute stroke patients regardless of tPA administration, after adjustment for relevant covariates. Further research into interventions regarding BP management poststroke is warranted.
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Affiliation(s)
- Shaun Ajinkya
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Eyad Almallouhi
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Nancy Turner
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Sami Al Kasab
- Department of Neurology, University of Iowa, Iowa City, Iowa, USA
| | - Christine A Holmstedt
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
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Alhazzani AA, Mahfouz AA, Abolyazid AY, Awadalla NJ, Katramiz K, Faraheen A, Khalil SN, Aftab R. In Hospital Stroke Mortality: Rates and Determinants in Southwestern Saudi Arabia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:E927. [PMID: 29735898 PMCID: PMC5981966 DOI: 10.3390/ijerph15050927] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 05/03/2018] [Accepted: 05/05/2018] [Indexed: 11/18/2022]
Abstract
Objectives: The present study analyzed in-hospital first-time stroke mortality in southwestern Saudi Arabia over one-year to assess the in-hospital stroke case fatality rate, mortality rate and explore the factors associated with in-hospital stroke mortality. Study Design: Hospital based follow-up study. Methods: First-time stroke patients admitted to all hospitals in Asser region over one-year period (January through December 2016) were included in the study. Data about personal characteristics, pre-stroke history and clinical criteria, on admission clinical criteria, in-hospital complications and survival status were collected. The last reported Aseer region population was used to calculate age and sex stroke mortality rate per 100,000 population/year. Hazard ratios (HR) and concomitant 95% confidence intervals (95% CI) were computed using multivariate Cox regression survival analysis. Kaplan-Meier curve survival analysis for stroke patients were plotted. Results: A total of 121 in-hospital deaths out of 1249 first-time stroke patients giving an overall case fatality rate (CFR) of 9.7%. Non-significant difference with gender and age were observed in CFR. Overall, in-hospital stroke mortality rate was 5.58 per 100,000/year. Males and elders showed a significantly higher mortality rates. Multivariable Cox regression analyses revealed pre-stroke smoking (HR = 2.36), pre-stroke hypertension (HR = 1.77), post-stroke disturbed consciousness (HR = 6.86), poor mobility (HR = 2.60) and developing pulmonary embolism (HR = 2.63) as significant predictors of in-hospital stroke mortality. Conclusions: In Southwestern Saudi Arabia, the in-hospital stroke mortality rate is higher in men and increases with aging. The prognosis of acute stroke could be improved by smoking cessation, better control of hypertension and prevention of in hospital complication particularly pulmonary embolism.
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Affiliation(s)
- Adel A Alhazzani
- Department of Internal Medicine, College of Medicine, King Khalid University, Abha 61421, Saudi Arabia.
| | - Ahmed A Mahfouz
- Department of Family and Community Medicine, College of Medicine, King Khalid University, P.O. Box 641, Abha 61421, Saudi Arabia.
- Department of Epidemiology, High Institute of Public Health, Alexandria University, Alexandria 21511, Egypt.
| | - Ahmed Y Abolyazid
- Department of Family and Community Medicine, College of Medicine, King Khalid University, P.O. Box 641, Abha 61421, Saudi Arabia.
- Department of Community Medicine, College of Medicine Mansoura University, Mansoura 35516, Egypt.
| | - Nabil J Awadalla
- Department of Family and Community Medicine, College of Medicine, King Khalid University, P.O. Box 641, Abha 61421, Saudi Arabia.
- Department of Community Medicine, College of Medicine Mansoura University, Mansoura 35516, Egypt.
| | - Khaled Katramiz
- Department of Neurology Section, Aseer Central Hospital, Saudi Arabia, Abha 21411, Saudi Arabia.
| | - Aesha Faraheen
- Department of Family and Community Medicine, College of Medicine, King Khalid University, P.O. Box 641, Abha 61421, Saudi Arabia.
| | - Shamsun Nahar Khalil
- Department of Family and Community Medicine, College of Medicine, King Khalid University, P.O. Box 641, Abha 61421, Saudi Arabia.
| | - Razia Aftab
- Department of Family and Community Medicine, College of Medicine, King Khalid University, P.O. Box 641, Abha 61421, Saudi Arabia.
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