Discrepant relationships between admission blood pressure and mortality in different stroke subtypes

Blood pressure variability predicts poor outcomes in acute stroke patients without thrombolysis: a systematic review and meta-analysis

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.

A Spatial Variation Analysis of In-Hospital Stroke Mortality Based on Integrated Pre-Hospital and Hospital Data in Mashhad, Iran

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.

Low blood pressure and adverse outcomes in acute stroke: HeadPoST study explanations

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.

The Relationship Between Admission Systolic Blood Pressure and Mortality in Telestroke Patients

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.

In Hospital Stroke Mortality: Rates and Determinants in Southwestern Saudi Arabia

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.