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Zhu Y, Wu M, Zheng Y, Wang X, Xiayang J, Zhang T, Wang S, Fang Z. Relationship of Day-by-Day Blood Pressure Variability and Admission Stroke Severity in Acute Ischemic Stroke. Neurologist 2024:00127893-990000000-00130. [PMID: 38444269 DOI: 10.1097/nrl.0000000000000556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
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.
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Affiliation(s)
- Yuan Zhu
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing
| | - Minghua Wu
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing
| | - Yawei Zheng
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing
| | - Xintong Wang
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing
| | - Jingyi Xiayang
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing
| | - Tianrui Zhang
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing
| | - Shana Wang
- Department of Clinical Medicine, Hangzhou Medical College, Hangzhou, China
| | - Zhuyuan Fang
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing
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2
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Biose IJ, Oremosu J, Bhatnagar S, Bix GJ. Promising Cerebral Blood Flow Enhancers in Acute Ischemic Stroke. Transl Stroke Res 2023; 14:863-889. [PMID: 36394792 PMCID: PMC10640530 DOI: 10.1007/s12975-022-01100-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: 09/28/2022] [Revised: 10/18/2022] [Accepted: 10/20/2022] [Indexed: 11/18/2022]
Abstract
Ischemic stroke presents a major global economic and public health burden. Although recent advances in available endovascular therapies show improved functional outcome, a good number of stroke patients are either ineligible or do not have access to these treatments. Also, robust collateral flow during acute ischemic stroke independently predicts the success of endovascular therapies and the outcome of stroke. Hence, adjunctive therapies for cerebral blood flow (CBF) enhancement are urgently needed. A very clear overview of the pial collaterals and the role of genetics are presented in this review. We review available evidence and advancement for potential therapies aimed at improving CBF during acute ischemic stroke. We identified heme-free soluble guanylate cyclase activators; Sanguinate, remote ischemic perconditioning; Fasudil, S1P agonists; and stimulation of the sphenopalatine ganglion as promising potential CBF-enhancing therapeutics requiring further investigation. Additionally, we outline and discuss the critical steps required to advance research strategies for clinically translatable CBF-enhancing agents in the context of acute ischemic stroke models.
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Affiliation(s)
- Ifechukwude Joachim Biose
- Department of Neurosurgery, Clinical Neuroscience Research Center, Tulane University School of Medicine, 131 S. Robertson, Ste 1300, Room 1349, New Orleans, LA, 70112, USA
| | - Jadesola Oremosu
- School of Medicine, Tulane University, New Orleans, LA, 70112, USA
| | - Somya Bhatnagar
- School of Medicine, Tulane University, New Orleans, LA, 70112, USA
| | - Gregory Jaye Bix
- Department of Neurosurgery, Clinical Neuroscience Research Center, Tulane University School of Medicine, 131 S. Robertson, Ste 1300, Room 1349, New Orleans, LA, 70112, USA.
- Tulane Brain Institute, Tulane University, New Orleans, LA, 70112, USA.
- Department of Neurology, Tulane University School of Medicine, New Orleans, LA, 70112, USA.
- Department of Microbiology and Immunology, Tulane University School of Medicine, New Orleans, LA, 70112, USA.
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, 70122, USA.
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3
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Kakaletsis N, Ntaios G, Milionis H, Karagiannaki A, Chouvarda I, Dourliou V, Chytas A, Hatzitolios AI, Savopoulos C. Prognostic significance of 24-h blood pressure and variability indices in the outcome of acute ischaemic stroke. Intern Med J 2023; 53:1137-1146. [PMID: 35666577 DOI: 10.1111/imj.15834] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 05/29/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The association between blood pressure (BP) levels and BP variability (BPV) following acute ischaemic stroke (AIS) and outcome remains controversial. AIMS To investigate the predictive value of systolic BP (SBP) and diastolic BP (DBP) and BPV measured using 24-h ambulatory blood pressure monitoring (ABPM) methods during AIS regarding outcome. METHODS A total of 228 AIS patients (175 without prior disability) underwent ABPM every 20 min within 48 h from onset using an automated oscillometric device (TM 2430, A&D Company Ltd) during day time (7:00-22:59) and night time (23:00-6:59). Risk factors, stroke subtypes, clinical and laboratory findings were recorded. Mean BP parameters and several BPV indices were calculated. End-points were death and unfavourable functional outcome (disability/death) at 3 months. RESULTS A total of 61 (26.7%) patients eventually died. Multivariate logistic regression analysis revealed that only mean night-time DBP (hazard ratio (HR): 1.04; 95% confidence interval (CI): 1.00-1.07) was an independent prognostic factor of death. Of the 175 patients without prior disability, 79 (45.1%) finally met the end-point of unfavourable functional outcome. Mean 24-h SBP (HR: 1.03; 95% CI: 1.00-1.05), day-time SBP (HR: 1.02; 95% CI: 1.00-1.05) and night-time SBP (HR: 1.03; 95% CI: 1.01-1.05), SBP nocturnal decline (HR: 0.93; 95% CI: 0.88-0.99), mean 24-h DBP (HR: 1.08; 95% CI: 1.03-1.13), day-time DBP (HR: 1.07; 95% CI: 1.03-1.12) and night-time DBP (HR: 1.06; 95% CI: 1.02-1.10) were independent prognostic factors of an unfavourable functional outcome. CONCLUSIONS In contrast with BPV indices, ABPM-derived BP levels and lower or absence of BP nocturnal decline in the acute phase are prognostic factors of outcome in AIS patients.
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Affiliation(s)
- Nikolaos Kakaletsis
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Haralampos Milionis
- Department of Internal Medicine, Medical School, University of Ioannina, University Hospital of Ioannina, Ioannina, Greece
| | - Anastasia Karagiannaki
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Ioanna Chouvarda
- Laboratory of Medical Informatics, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasiliki Dourliou
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Achileas Chytas
- Laboratory of Medical Informatics, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Apostolos I Hatzitolios
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Christos Savopoulos
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
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Manolis AJ, Kallistratos MS, Camafort M, Coca A. How low should blood pressure be in patients with chronic coronary and cerebrovascular diseases. Eur J Intern Med 2023; 109:22-29. [PMID: 36631307 DOI: 10.1016/j.ejim.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/03/2023] [Accepted: 01/05/2023] [Indexed: 01/11/2023]
Abstract
Over the last three decades, there are an increasing number of investigators and meta-analyses focusing on the fact that lowering blood pressure levels below a critical point is no longer beneficial and possibly even deleterious. In recent years, several trials and meta-analyses assessing intensive blood pressure (BP) lowering found that intensive treatment and lower blood pressure levels are associated with a reduction in CV events and mortality. However, a careful examination of the results shows that current data are not easily applicable to the general hypertensive population. In addition, recommendations of different guidelines since 2017 so far suggest different BP levels regarding the systolic and diastolic thresholds to be achieved and maintained, particularly in specific clinical situations such as patients with coronary artery disease and stroke. The challenge is to better define the limits of intervention and to define phenotypes of patients who are particularly vulnerable to over-aggressive lowering of blood pressure. This article reviews the evidence, controversies and current state of knowledge regarding intensive BP lowering and the lower thresholds of BP to be achieved in patients with chronic coronary or cerebrovascular diseases.
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Affiliation(s)
- A J Manolis
- Cardiology Department, Metropolitan Hospital, Piraeus, Greece
| | | | - M Camafort
- Hypertension and Vascular Risk Unit, Department of Internal Medicine. Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - A Coca
- Hypertension and Vascular Risk Unit, Department of Internal Medicine. Hospital Clínic, University of Barcelona, Barcelona, Spain
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5
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Zhu Y, Wu M, Wang H, Zheng Y, Zhang S, Wang X, Wang S, Fang Z. Daily blood pressure variability in relation to neurological functional outcomes after acute ischemic stroke. Front Neurol 2023; 13:958166. [PMID: 36698896 PMCID: PMC9868909 DOI: 10.3389/fneur.2022.958166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 11/25/2022] [Indexed: 01/12/2023] Open
Abstract
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.
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Affiliation(s)
- Yuan Zhu
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Minghua Wu
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Huihui Wang
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Yawei Zheng
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Siqi Zhang
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Xintong Wang
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Shana Wang
- Department of Clinical Medicine, Hangzhou Medical College, Hangzhou, China
| | - Zhuyuan Fang
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China,*Correspondence: Zhuyuan Fang ✉
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6
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Fukuda K, Matsuo R, Kamouchi M, Kiyuna F, Sato N, Nakamura K, Hata J, Wakisaka Y, Ago T, Imaizumi T, Kai H, Kitazono T. Day-by-Day Blood Pressure Variability in the Subacute Stage of Ischemic Stroke and Long-Term Recurrence. Stroke 2021; 53:70-78. [PMID: 34496621 DOI: 10.1161/strokeaha.120.033751] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Kenji Fukuda
- Department of Medicine and Clinical Science (K.F., R.M., F.K., N.S., K.N., J.H., Y.W., T.A., T.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Cerebrovascular Disease, St. Mary's Hospital, Kurume, Japan (K.F.).,Department of Internal Medicine, Division of Cardio-Vascular Medicine, Kurume University School of Medicine, Japan (K.F., T.I.)
| | - Ryu Matsuo
- Department of Medicine and Clinical Science (K.F., R.M., F.K., N.S., K.N., J.H., Y.W., T.A., T.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Health Care Administration and Management (R.M., M.K., N.S.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masahiro Kamouchi
- Department of Health Care Administration and Management (R.M., M.K., N.S.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Center for Cohort Studies (M.K., J.H., T.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Fumi Kiyuna
- Department of Medicine and Clinical Science (K.F., R.M., F.K., N.S., K.N., J.H., Y.W., T.A., T.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Noriko Sato
- Department of Medicine and Clinical Science (K.F., R.M., F.K., N.S., K.N., J.H., Y.W., T.A., T.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Health Care Administration and Management (R.M., M.K., N.S.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kuniyuki Nakamura
- Department of Medicine and Clinical Science (K.F., R.M., F.K., N.S., K.N., J.H., Y.W., T.A., T.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Jun Hata
- Department of Medicine and Clinical Science (K.F., R.M., F.K., N.S., K.N., J.H., Y.W., T.A., T.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Center for Cohort Studies (M.K., J.H., T.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Epidemiology and Public Health (J.H.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshinobu Wakisaka
- Department of Medicine and Clinical Science (K.F., R.M., F.K., N.S., K.N., J.H., Y.W., T.A., T.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tetsuro Ago
- Department of Medicine and Clinical Science (K.F., R.M., F.K., N.S., K.N., J.H., Y.W., T.A., T.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tsutomu Imaizumi
- Department of Internal Medicine, Division of Cardio-Vascular Medicine, Kurume University School of Medicine, Japan (K.F., T.I.).,Fukuoka International University of Health and Welfare, Japan (T.I.)
| | - Hisashi Kai
- Department of Cardiology, Kurume University Medical Center, Japan (H.K.)
| | - Takanari Kitazono
- Department of Medicine and Clinical Science (K.F., R.M., F.K., N.S., K.N., J.H., Y.W., T.A., T.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Center for Cohort Studies (M.K., J.H., T.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Zheng X, Peng Y, Zhong C, Xie X, Wang A, Zhu Z, Xu T, Peng H, Xu T, Wang D, Ju Z, Geng D, Chen J, Liu L, He J, Zhang Y. Systolic Blood Pressure Trajectories After Discharge and Long-Term Clinical Outcomes of Ischemic Stroke. Hypertension 2021; 77:1694-1702. [PMID: 33745302 DOI: 10.1161/hypertensionaha.120.16881] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Xiaowei Zheng
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Medical College of Soochow University, Suzhou, China (X.Z., C.Z., A.W., Z.Z., T.X., H.P., T.X., Y.Z.).,Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA (X.Z., J.C., J.H.)
| | - Yanbo Peng
- Department of Neurology, Affiliated Hospital of North China University of Science and Technology, Tangshan (Y.P., D.W.)
| | - Chongke Zhong
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Medical College of Soochow University, Suzhou, China (X.Z., C.Z., A.W., Z.Z., T.X., H.P., T.X., Y.Z.)
| | - Xuewei Xie
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (X.X., L.L.)
| | - Aili Wang
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Medical College of Soochow University, Suzhou, China (X.Z., C.Z., A.W., Z.Z., T.X., H.P., T.X., Y.Z.)
| | - Zhengbao Zhu
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Medical College of Soochow University, Suzhou, China (X.Z., C.Z., A.W., Z.Z., T.X., H.P., T.X., Y.Z.)
| | - Tan Xu
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Medical College of Soochow University, Suzhou, China (X.Z., C.Z., A.W., Z.Z., T.X., H.P., T.X., Y.Z.).,Department of Neurology, Affiliated Hospital of Nantong University, China (T.X.)
| | - Hao Peng
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Medical College of Soochow University, Suzhou, China (X.Z., C.Z., A.W., Z.Z., T.X., H.P., T.X., Y.Z.)
| | - Tian Xu
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Medical College of Soochow University, Suzhou, China (X.Z., C.Z., A.W., Z.Z., T.X., H.P., T.X., Y.Z.).,Department of Neurology, Affiliated Hospital of Nantong University, China (T.X.)
| | - Dali Wang
- Department of Neurology, Affiliated Hospital of North China University of Science and Technology, Tangshan (Y.P., D.W.)
| | - Zhong Ju
- Department of Neurology, Kerqin District First People's Hospital of Tongliao City, China (Z.J.)
| | - Deqin Geng
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, China (D.G.)
| | - Jing Chen
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA (X.Z., J.C., J.H.).,Department of Medicine, Tulane University School of Medicine, New Orleans, LA (J.C., J.H.)
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (X.X., L.L.)
| | - Jiang He
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA (X.Z., J.C., J.H.).,Department of Medicine, Tulane University School of Medicine, New Orleans, LA (J.C., J.H.)
| | - Yonghong Zhang
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Medical College of Soochow University, Suzhou, China (X.Z., C.Z., A.W., Z.Z., T.X., H.P., T.X., Y.Z.)
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Sandset EC, Wang X, Carcel C, Sato S, Delcourt C, Arima H, Stapf C, Robinson T, Lavados P, Chalmers J, Woodward M, Anderson CS. Sex differences in treatment, radiological features and outcome after intracerebral haemorrhage: Pooled analysis of Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage trials 1 and 2. Eur Stroke J 2020; 5:345-350. [PMID: 33598552 DOI: 10.1177/2396987320957513] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 08/14/2020] [Indexed: 11/16/2022] Open
Abstract
Introduction Reports vary on how sex influences the management and outcome from acute intracerebral haemorrhage. We aimed to quantify sex disparities in clinical characteristics, management, including response to blood pressure lowering treatment, and outcomes in patients with acute intracerebral haemorrhage, through interrogation of two large clinical trial databases. Patients and Methods Post-hoc pooled analysis of the Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage trials 1 and 2, where patients with a hypertensive response (systolic, 150-220 mmHg) after spontaneous intracerebral haemorrhage (<6 h) were randomised to intensive (target <140 mmHg <1 h) or guideline-recommended (<180 mmHg) blood pressure lowering treatment. The interaction of sex on early haematoma growth (24 h), death or major disability (modified Rankin scale scores 3-6 at 90 days), and effect of randomised treatment were determined in multivariable logistic regression models adjusted for baseline confounding variables. Results In 3233 participants, 1191 (37%) were women who were significantly older, had higher baseline National Institutes of Health Stroke Scale scores and smaller haematoma volumes compared to men. Men had higher three-month mortality (odds ratio 1.48, 95% confidence interval 1.10-2.00); however, there was no difference between women and men in the combined endpoint of death or major disability. There were no significant sex differences on mean haematoma growth or effect of randomised blood pressure lowering treatment. Discussion Men included in the Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage trials had more comorbidities, larger baseline haematoma volumes and higher mortality after adjustment for age, as compared with women. Conclusion Men included in the Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage trials had a greater odds of dying after intracerebral haemorrhage than women, which could not be readily explained by differing casemix or patterns of blood pressure management. Clinical trial registration The Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage trials studies are registered with ClinicalTrials.gov (NCT00226096 and NCT00716079).
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Affiliation(s)
| | - Xia Wang
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.,Central Clinical School, University of Sydney, Sydney, Australia
| | - Cheryl Carcel
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.,Central Clinical School, University of Sydney, Sydney, Australia.,Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia
| | - Shoichiro Sato
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.,Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Candice Delcourt
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.,Central Clinical School, University of Sydney, Sydney, Australia.,Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia
| | - Hisatomi Arima
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.,Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Christian Stapf
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Département de Neurosciences, Université de Montréal, Montréal, Canada
| | - Thompson Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Pablo Lavados
- Unidad de Neurología vascular, Servicio de Neurología, Departamento de Medicina, Clínica Alemana; Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - John Chalmers
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.,Central Clinical School, University of Sydney, Sydney, Australia.,Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia
| | - Mark Woodward
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.,The George Institute for Global Health, Imperial College London, UK.,Department of Epidemiology, Johns Hopkins University, Baltimore, USA
| | - Craig S Anderson
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.,Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia.,The George Institute China at Peking University Health Science Center, Beijing, China
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AlHarfany H, Haidar L, Cherri S, Malaeb D, Salameh P, Hosseini H. Assessment of acute treatment of hypertension in ischemic stroke patients. Clin Neurol Neurosurg 2020; 195:105949. [PMID: 32505063 DOI: 10.1016/j.clineuro.2020.105949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 05/10/2020] [Accepted: 05/19/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Stroke, the most common neurologic disorder and the major cause of disability and death after heart disease causing 11.8% of the total deaths worldwide, is defined as a rapidly developing clinical signs of focal disturbance of cerebral function lasting more than 24 h. This study aims to assess appropriateness of hypertension treatment in acute stroke and its adherence with the choice of medications tailored according to blood pressure readings. PATIENTS AND METHODS This was a pilot study performed in Lebanese hospitals where medical records of ischemic stroke patients were used to collect required data. The study enrolled ischemic stroke patients older than 18 years of age, admitted to intensive care unit or internal medicine department. Patients with hemorrhagic stroke were excluded. Statistical analysis was done using IBM Statistical Package for the Social Science software. The significance level is p-value ≤ 0.05. RESULTS A total of 146 patients (56.8% females; mean age 76.6 ± 11.9) were included in the analysis. At baseline, patients had a mean ± standard deviation (SD) SBP of 160.6 (±31.3) and a mean DBP of 85.5. Labetalol and amlodipine were administered to patients with significantly higher baseline blood pressure (p < 0.001). Change in SBP from baseline after 2 h of drug administration was significantly higher with labetalol (p = 0.028 for patients eligible for reperfusion), amlodipine (p = 0.014), and nitroglycerine (p = 0.044). As for the change in SBP after 24 h, it was significantly higher with labetalol just for patients not eligible for reperfusion (p < 0.001), and amlodipine (p = 0.006). As for the change in DBP, it was significantly lower after 24 h on labetalol administration for patients not eligible for reperfusion (p < 0.001) and it was also lower 2 h after administration of ramipril (p = 0.001) and 24 h (p = 0.021). CONCLUSION This study reveals the gap between American Stroke Association guideline recommendations and the clinical practice and states the impact of such a difference on patients' health.
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Affiliation(s)
- Hiba AlHarfany
- School of Pharmacy, Lebanese International University, Mouseitbeh, PO Box: 146404, Beirut, Lebanon.
| | - Lara Haidar
- School of Pharmacy, Lebanese International University, Mouseitbeh, PO Box: 146404, Beirut, Lebanon.
| | - Sarah Cherri
- School of Pharmacy, Lebanese International University, Mouseitbeh, PO Box: 146404, Beirut, Lebanon.
| | - Diana Malaeb
- School of Pharmacy, Lebanese International University, Mouseitbeh, PO Box: 146404, Beirut, Lebanon; Life Sciences and Health Department, Paris-Est University, Paris, France.
| | - Pascale Salameh
- INSPECT-LB: Institut National de Santé Publique, Epidémiologie Clinique et Toxicologie, Beirut, Lebanon; Faculty of Pharmacy, Lebanese University, Hadath, Lebanon; Faculty of Medicine, Lebanese University, Hadath, Lebanon.
| | - Hassan Hosseini
- Life Sciences and Health Department, Paris-Est University, Paris, France; Henri Mondor Hospital, Paris, France.
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Increased blood pressure variability during the subacute phase of ischemic stroke is associated with poor functional outcomes at 3 months. Sci Rep 2020; 10:811. [PMID: 31964961 PMCID: PMC6972830 DOI: 10.1038/s41598-020-57661-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 01/02/2020] [Indexed: 01/13/2023] Open
Abstract
Thus far, it is well known that increased blood pressure variability may exacerbate stroke outcomes. Blood pressure in the acute phase would be influenced by both reactive hypertension to stroke and intrinsic blood pressure reactivity. Thus, we aimed to evaluate the association between blood pressure variability and outcomes at 3 months using ambulatory blood pressure monitoring in ischemic stroke patients in the subacute phase after reactive hypertension subsided. We retrospectively examined 626 consecutive patients with acute ischemic stroke who underwent 24-hour ambulatory blood pressure monitoring during the subacute phase of stroke (median, 9 days from onset). The variability in blood pressure was evaluated by assessing the standard deviation and coefficient of variation of systolic and diastolic blood pressure. The primary outcome was functional status at 3 months. A poor outcome was defined as a modified Rankin scale score of 3 or more and a good outcome as 2 or less. We assessed the functional outcome at 3 months in 497 patients (79.4%). The mean systolic and diastolic blood pressure levels were not associated with functional outcome. The multivariable analysis revealed that increases in the standard deviations of systolic and diastolic blood pressure, coefficient of variation of diastolic blood pressure, and morning blood pressure surge were associated with poor outcome. Blood pressure variability during the subacute phase of ischemic stroke can be a useful prognostic indicator of poor functional outcome at 3 months in patients with acute ischemic stroke.
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11
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Blood pressure variability in subacute stage and risk of major vascular events in ischemic stroke survivors. J Hypertens 2019; 37:2000-2006. [DOI: 10.1097/hjh.0000000000002126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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12
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Associations between change in blood pressure and functional outcome, early events and death: results from the Efficacy of Nitric Oxide in Stroke trial. J Hypertens 2019; 37:2104-2109. [PMID: 31246895 PMCID: PMC6727949 DOI: 10.1097/hjh.0000000000002154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
High blood pressure (BP) is associated with a poor outcome after acute stroke. Early reduction in BP may be associated with fewer early adverse events and deaths, and improved functional outcome.
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13
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Vanaie M, Valiyan Boroujeni M, Motavallipour Abarghuie H, Pourshanazari AA, Rezazadeh H. The Effect of Sneezing on the Reduction of Infarct Volume and the Improvement of Neurological Deficits in Male Rats. Adv Biomed Res 2018; 7:142. [PMID: 30596052 PMCID: PMC6282486 DOI: 10.4103/abr.abr_119_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background Sneezing transiently elevates cerebral blood flow. We speculated that induced sneezing, following embolism would restore arterial flow, thereby diminishing infarct volume and improving neurological deficits. Materials and Methods Male rats were subjected to middle cerebral artery occlusion (MCAO) using prepared clots (embolization) and randomized into four equal groups as follows: (1) pre-MCAO-induced sneezing (PRMIS), (2) post-MCAO-induced sneezing (POMIS), and (3) pre- and POMIS (PRPOMIS) and the control group (eight rats per group). In the treatment groups, rats' sneezing episodes were induced before MCAO in PRMIS group or before regaining consciousness from surgical anesthesia in other treatment groups by cutting their whiskers during their anesthesia and subsequently inserted them into the rats' nostrils. Infarct volume was evaluated by 2, 3, 5-triphenyl tetrazolium chloride staining, and neurological deficits and brain edema were assessed by Bederson scale deficit scores 24-h post-MCAO. Results The infarct volume and brain edema reduced and neurological deficits improved in the induced sneezing groups as compared with the MCAO control group. Compared to the control group, the highest improvements in the infarct volume and neurological deficits were seen in the PRPOMIS group, and POMIS group showed the most significant differences concerning the results of both ischemic and nonischemic brain edema. The highest protective effect was observed in the central region of the MCA territory. Conclusions The reduction in ischemia-induced brain injury, brain edema, and neurological deficits by sneezing suggest that brief episodes of acute hypertension after stroke can increase blood flow to the ischemic area and improve recovery.
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Affiliation(s)
- Mahdi Vanaie
- School of Medicine, Medical Student Research Committee, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Majid Valiyan Boroujeni
- School of Medicine, Medical Student Research Committee, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Ali Asghar Pourshanazari
- School of Medicine, Medical Student Research Committee, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hossein Rezazadeh
- Physiology - Pharmacology Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
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Bager J, Hjalmarsson C, Manhem K, Andersson B. Acute blood pressure levels and long-term outcome in ischemic stroke. Brain Behav 2018; 8:e00992. [PMID: 29777579 PMCID: PMC5991576 DOI: 10.1002/brb3.992] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 04/08/2018] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES Elevated blood pressure (BP) is common in acute ischemic stroke, but its effect on outcome is not fully understood. We aimed to investigate the association of baseline BP and BP change within the first day after stroke with stroke severity, functional outcome, and mortality. METHODS Patients admitted to hospital with acute ischemic stroke (IS) from 15 February 2005 through 31 May 2009 were consecutively included. Acute stroke severity and functional outcome at three and twelve months were investigated using multivariate regression analysis; the association between BP and all-cause mortality at one, three, and twelve was investigated by Cox proportional hazard regression and Kaplan-Meier survival curves. RESULTS A total of 799 patients (mean age 78.4 ± 8.0, 48% men) were included. Higher decreases in systolic and mean arterial blood pressure (ΔSBP and ΔMAP) were associated with decreased 1-month mortality (ΔSBP: hazard ratio, HR: 0.981; 95% CI: 0.968 - 0.994; p = .005), 3-month mortality (ΔSBP: HR 0.989; 95% CI 0.981 - 0.998; p-value .014), and twelve-month mortality (ΔSBP: HR 0.989; 95% CI 0.982 - 0.996; p-value .003). Stroke severity was associated with ΔMAP (B coefficient -.46, p-value .011). Higher SBP and MAP on admission were associated with better functional outcome at three (SBP: OR 0.987; 95% CI 0.978 - 0.997; p-value .008 - MAP: OR 0.985; 95% CI 0.971 - 1; p-value .046) and twelve (SBP: OR 0.988; 95% CI 0.979 - 0.998; p-value .015 - MAP: OR 0.983; 95% CI 0.968 - 0.997; p-value .02) months. CONCLUSION In this elderly population, higher BP on arrival to the emergency room (ER) and decrease in BP after the patients' arrival to the ward were associated with improved functional outcome and reduced mortality, respectively. These results may reflect a regulatory situation in which elevated initial blood pressure indicates adequate response to cerebral tissue ischemia while subsequent blood pressure decrease instead may be a consequence of partial, successful reperfusion.
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Affiliation(s)
- Johan‐Emil Bager
- Department of Internal MedicineSahlgrenska University HospitalGöteborgSweden
| | - Clara Hjalmarsson
- Department of CardiologySahlgrenska University HospitalGöteborgSweden
| | - Karin Manhem
- Institute of MedicineDepartment of Molecular and Clinical MedicineSahlgrenska University HospitalSahlgrenska AcademyUniversity of GothenburgGöteborgSweden
| | - Bjorn Andersson
- The Stroke UnitDepartment of Internal MedicineSahlgrenska University HospitalGöteborgSweden
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15
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16
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Kang J, Hong JH, Jang MU, Choi NC, Lee JS, Kim BJ, Han MK, Bae HJ. Change in blood pressure variability in patients with acute ischemic stroke and its effect on early neurologic outcome. PLoS One 2017; 12:e0189216. [PMID: 29252991 PMCID: PMC5734725 DOI: 10.1371/journal.pone.0189216] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Accepted: 11/17/2017] [Indexed: 11/19/2022] Open
Abstract
Background How short-term blood pressure variability (BPV) is affected in the acute stage of ischemic stroke and whether BPV is associated with early neurologic outcomes remains unclear. Methods Patients who admitted for ischemic stroke within 24 h of symptom onset were consecutively identified between January 2010 and January 2015. BP profiles measured in real-time were summarized into short-term, 24-h time intervals, based on standard deviation (SD) and mean of systolic BP (SBPSD) during the first 3 days. The primary outcome was daily assessment of early neurological deterioration (END). The associations between short-term SBPSD values and the secular trend for primary outcome were examined. Results A total of 2,545 subjects (mean age, 67.1 ± 13.5 years old and median baseline National Institutes of Health Stroke Scale score, 3) arrived at the hospital an average of 6.1 ± 6.6 h after symptom onset. SBPSD values at day 1 (SD#D1), SD#D2, and SD#D3 were 14.4 ± 5.0, 12.5 ± 4.5, and 12.2 ± 4.6 mmHg, respectively. Multivariable analyses showed that SD#D2 was independently associated with onset of END at day 2 (adjusted odds ratio, 1.08; 95% confidence interval, 1.03–1.13), and SD#D3 was independently associated with END#D3 (1.07, 1.01–1.14), with adjustments for predetermined covariates, SBPmean, and interactions with daily SBPSD. Conclusion Short-term BPV changed and stabilized from the first day of ischemic stroke. Daily high BPV may be associated with neurological deterioration independent of BPV on the previous day.
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Affiliation(s)
- Jihoon Kang
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University, Seongnam, Republic of Korea
- * E-mail: ,
| | - Jeong-Ho Hong
- Department of Neurology, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Min Uk Jang
- Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University, School of Medicine, Dongtan, Republic of Korea
| | - Nack Cheon Choi
- Department of Neurology, Gyneongsang Institute for Neuroscience, Gyengsang National University College of Medicine, Jinju, Republic of Korea
| | - Ji Sung Lee
- Clinical Research Center, Asan Medical Center, Ulsan University School of Medicine, Seoul, Republic of Korea
| | - Beom Joon Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University, Seongnam, Republic of Korea
| | - Moon-Ku Han
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University, Seongnam, Republic of Korea
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University, Seongnam, Republic of Korea
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17
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Maier IL, Tsogkas I, Behme D, Bähr M, Knauth M, Psychogios MN, Liman J. High Systolic Blood Pressure after Successful Endovascular Treatment Affects Early Functional Outcome in Acute Ischemic Stroke. Cerebrovasc Dis 2017; 45:18-25. [PMID: 29176326 DOI: 10.1159/000484720] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 10/25/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Endovascular treatment (EVT) has been shown to significantly improve functional outcome in patients with acute large cerebral vessel occlusions. To date, no evidence-based recommendations on blood pressure management after successful EVT exist. Previous studies showed an association between high pre-EVT systolic blood pressure (SBP) and functional outcome, but do not answer the question on how to manage blood pressure after successful recanalization. The purpose of this study was to determine the role of blood pressure measurements as a predictor for early functional outcome in patients with successful EVT. METHODS Prospectively derived data from patients with acute large vessel occlusion within the anterior circulation and EVT was analyzed in this monocentric study. Mean systolic- and maximum SBP as well as SBP-peaks have been obtained for the first 24 h after successful EVT. Predictive value of SBP for discharge modified Rankin Scale (mRS) ≤2 has been investigated using logistic regression models. RESULTS From 168 patients with successful EVT, 74 (44%) had a favorable outcome with an mRS ≤2. Mean- (127 vs. 131 mm Hg, p = 0.035) and maximum SBP (157 vs. 169 mm Hg, p < 0.001) as well as the number of SBP-peaks (0 vs. 1.5, p = 0.004) were lower in patients with favorable outcomes. Multivariable logistic regression showed high mean- and maximum SBP to predict unfavorable outcomes. Cutoff mean SBP was 141 mm Hg and maximum SBP 159 mm Hg. CONCLUSIONS High SBP in the first 24 h after recanalization of acute anterior cerebral vessel occlusions is associated with unfavorable functional outcome. Interventional studies are needed to determine the role of SBP management as a modifiable parameter in the early phase after successful EVT.
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Affiliation(s)
- Ilko L Maier
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Ioannis Tsogkas
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - Daniel Behme
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - Mathias Bähr
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Michael Knauth
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | | | - Jan Liman
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
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Shi Z, Li ES, Zhong JS, Yuan JL, Li LR, Zheng CW. Predictive Significance of Day-to-Day Blood Pressure Variability in Acute Ischemic Stroke for 12-Month Functional Outcomes. Am J Hypertens 2017; 30:524-531. [PMID: 28203689 DOI: 10.1093/ajh/hpx005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 01/15/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Previous studies on the association between blood pressure (BP) variability in acute ischemic stroke and functional outcomes have yielded conflicting results. We aimed to investigate the predictive significance of day-to-day BP variability during the 7 days following stroke onset for functional outcomes at 12 months. METHODS A total of 229 patients (male 68.8%, mean age 66.7 ± 13.0 years) within 24 hours after onset were prospectively studied. The first 24 hours and day-to-day BP variability, including the SD, coefficient variation (CV), average real variation, and ΔBP (difference between the maximum and minimum BP), were derived and compared to functional outcomes. The functional outcomes were accessed using the baseline severity-adjusted analysis at 12 months post-stroke. RESULTS The patients with poor outcomes at 12 months had significantly higher morning systolic BP (SBP; 1-3 days after onset) than those with good outcomes. The day-to-day SBP variability parameters (1-7 days) such as SD, CV, and Δ SBP were significantly higher in the patients with poor outcomes than in those with good outcomes (17.0 ± 6.0 vs. 14.8 ± 5.3 mm Hg, 11.8 ± 3.9 vs. 10.6 ± 3.5, 48.3 ± 17.7 vs. 39.9 ± 15.5 mm Hg, respectively; P < 0.05). After adjustment for demographic and clinical features, day-to-day Δ SBP was associated with poorer functional outcomes at 12 months (odds ratio, 95% confidence interval: 1.547, 1.097-2.181). Even after adjusting for the mean SBP, Δ SBP was independently associated with 12-month poor functional outcomes (odds ratio, 95% confidence interval: 1.577, 1.095-2.272). CONCLUSIONS Day-to-day SBP variability in acute ischemic stroke was associated with poor functional outcomes at 12 months. CLINICAL TRIALS REGISTRATION Trial Number NCT02675972.
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Affiliation(s)
- Zhu Shi
- Department of Neurology, Dongguan People's Hospital, Dongguan, PR China
| | - En S Li
- Department of Neurology, Dongguan People's Hospital, Dongguan, PR China
| | - Jun S Zhong
- Department of Neurology, Dongguan People's Hospital, Dongguan, PR China
| | - Juan L Yuan
- Department of Neurology, Dongguan People's Hospital, Dongguan, PR China
| | - Lan R Li
- Department of Neurology, Dongguan People's Hospital, Dongguan, PR China
| | - Cheng W Zheng
- Department of Neurology, Dongguan People's Hospital, Dongguan, PR China
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Nelson S, Cloonan L, Kanakis AS, Fitzpatrick KM, Shideler KI, Perilla AS, Furie KL, Rost NS. Antecedent Aspirin Use Is Associated with Less Severe Symptoms on Admission for Ischemic Stroke. J Stroke Cerebrovasc Dis 2016; 25:2519-25. [PMID: 27444522 DOI: 10.1016/j.jstrokecerebrovasdis.2016.06.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 05/08/2016] [Accepted: 06/22/2016] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Aspirin is known to reduce stroke risk; however, its role in reducing severity of ischemic syndrome is not clear. We sought to investigate the relationship between antecedent aspirin use and stroke severity in patients presenting with acute ischemic stroke (AIS). METHODS We retrospectively analyzed a prospectively collected database of consecutive AIS patients presenting to our center. Clinical characteristics (including antecedent aspirin use), imaging findings, and laboratory data were assessed in association with presenting stroke severity, as measured by the National Institutes of Health Stroke Scale (NIHSS). Logistic regression models were used to determine univariate and multivariate predictors of baseline NIHSS. RESULTS Of the 610 AIS patients with admission brain magnetic resonance imaging available for volumetric analysis of acute infarct size, 241 (39.5%) used aspirin prior to stroke onset. Antecedent aspirin use (P = .0005), history of atrial fibrillation (P < .0001), acute infarct volume (P < .0001), initial systolic blood pressure (P = .041), admission glucose level (P = .0027), and stroke subtype (P < .0001) were associated with presenting stroke severity in univariate analysis. Antecedent aspirin use (P < .0001), history of atrial fibrillation (P < .0002), acute infarct volume (P < .0001), systolic blood pressure (P = .038), and glucose level (P = .0095) remained independent predictors of NIHSS in multivariable analysis. CONCLUSIONS Antecedent aspirin use was independently associated with milder presenting stroke severity, even after accounting for acute infarct volume. While the underlying biology of this apparent protective relationship requires further study, patients at high risk of stroke may benefit from routine aspirin use.
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Affiliation(s)
- Sarah Nelson
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts.
| | - Lisa Cloonan
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Allison S Kanakis
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Kaitlin M Fitzpatrick
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Kelsey I Shideler
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Adriana S Perilla
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Karen L Furie
- Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Natalia S Rost
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
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Weiss A, Beloosesky Y, Kenett RS, Grossman E. Change in Systolic Blood Pressure During Stroke, Functional Status, and Long-Term Mortality in an Elderly Population. Am J Hypertens 2016. [PMID: 26208674 DOI: 10.1093/ajh/hpv118] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Elevated systolic blood pressure (SBP) recorded by 24-hour blood pressure monitoring (24H BPM) on the first day of acute stroke is associated in elderly patients, with an unfavorable outcome. Herein, we assessed, by 24H BPM, the impact of the change in SBP levels during the first week of stroke on short-term functional status and long-term mortality in elderly patients. METHODS One hundred and fifty acute stroke patients (69 males), mean age at admission 83.6±5.5 years, 82% with ischemic stroke, were investigated. 24H BPM was recorded within 24 hours of admission and 1 week later. After 7 days, patients were assessed for functional status according to the modified Rankin scale (mRS) and were subsequently followed for mortality up to 7.5 years (mean 3.16±2.29). RESULTS After 7 days, SBP decreased from 147±21 to 140±20 mm Hg (P < 0.001). Functional status improved and mRS decreased from 4.2 to 3.7. During follow-up, 58 patients (17 males and 41 females) had died. Mortality rate was higher in females (69% vs. 45%; P < 0.01) and in patients with a history of congestive heart failure. The average admission SBP predicted short-term functional status and long-term mortality. However, the change in SBP corrected for admission levels, gender, age and other variables was not associated with short-term functional status and long-term mortality. CONCLUSION There is no evidence of association between change in SBP during the first week of stroke and short-term functional status and long-term mortality in this group of stroke patients.
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Affiliation(s)
- Avraham Weiss
- Geriatric Ward, Rabin Medical Center, Petach Tikvah, Israel
| | | | | | - Ehud Grossman
- Department of Internal Medicine D and Hypertension Unit, The Chaim Sheba Medical Center, Tel-Hashomer, Affiliated to Sackler School of Medicine, Tel-Aviv University, Israel.
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Wu W, Huo X, Zhao X, Liao X, Wang C, Pan Y, Wang Y, Wang Y. Relationship between Blood Pressure and Outcomes in Acute Ischemic Stroke Patients Administered Lytic Medication in the TIMS-China Study. PLoS One 2016; 11:e0144260. [PMID: 26828609 PMCID: PMC4735460 DOI: 10.1371/journal.pone.0144260] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 11/16/2015] [Indexed: 02/05/2023] Open
Abstract
Objective Increased blood pressure (BP) management following acute ischemic stroke (AIS) remains controversial. This study aimed to identify the association between BP and clinical outcomes in AIS patients administered lytic medication in the TIMS-China (thrombolysis implementation and monitor of acute ischemic stroke in China) database. Methods The sample comprised 1128 patients hospitalized within 4.5 hours (h) of AIS for intravenous recombinant tissue plasminogen activator (i.v. rt-PA) thrombolysis. Systolic BP (SBP) and diastolic BP (DBP) at baseline, 2 h and 24 h after treatment, and changes from baseline were analyzed. The study outcomes comprised a favorable outcome (modified Rankin Scale 0–1 at 90 days) and symptomatic intracerebral hemorrhage (SICH), analyzed using logistic regression, with low BP as the reference group. Results Lower BP (baseline, 2 h, and 24 h) was beneficial in AIS patients and significantly related to a favorable outcome (P<0.05). A substantial BP decrease at 24 h after rt-PA thrombolysis was significantly associated with a favorable outcome compared with a moderate BP decrease (P = 0.0298). A SBP >160 mmHg 2 h after rt-PA thrombolysis was significantly associated with SICH compared with a SBP <140 mmHg (P = 0.0238). An increase or no change (>25 mmHg) in SBP was significantly associated with SICH (P = 0.002) compared with a small SBP decrease (1–9 mmHg). Conclusions This study provides novel evidence that lower BP within the first 24 h is associated with a more favorable outcome and less frequent SICH in AIS patients administered lytic medication. Routine BP-lowering treatment should be considered in AIS patients following lytic medication.
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Affiliation(s)
- Wei Wu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of neurology, Qilu Hospital of Shandong University, Jinan China & Braian Science Research Institute, Shandong University, Jinan, China
| | - Xiaochuan Huo
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaoling Liao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chunjuan Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- * E-mail: (YW); (YW)
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- * E-mail: (YW); (YW)
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22
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Yan S, Liu K, Cao J, Liebeskind DS, Lou M. "Sudden Drop" in Blood Pressure is Associated With Recanalization After Thrombolysis. Medicine (Baltimore) 2015. [PMID: 26222844 PMCID: PMC4554120 DOI: 10.1097/md.0000000000001132] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We aim to investigate whether the phenomenon of "sudden drop" in blood pressure (BP) within the first 2 hours is associated with vessel recanalization.We retrospectively examined clinical and imaging data from a consecutive series of patients with stroke with large vessel occlusion treated with intravenous thrombolysis (IVT). BP was monitored every 15 minutes during the first 2 hours, then every 30 minutes for 6 hours, and then every hour for 16 hours.We observed the phenomenon of "sudden drop" in systolic BP (≥20 mm Hg) in 82 (50.9%) patients in the first 2 hours and vessel recanalization in 87 (54.0%) patients 24 hours after treatment. This phenomenon was independently associated with recanalization (odds ratio 2.100; 95% confidence interval: 1.085-4.062; P = 0.028) after adjusting for the history of atrial fibrillation, coronary heart disease, and hypertension.The phenomenon of "sudden drop" in systolic BP with 20 mm Hg or greater between 2 continuous measurements within the first 2 hours is associated with recanalization after IVT in patients with large vessel occlusion, especially for middle cerebral artery occlusion.
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Affiliation(s)
- Shenqiang Yan
- From the Department of Neurology (SY, KL, JC, ML), Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China; and University of California-Los Angeles Stroke Center (DSL), Los Angeles, California
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23
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Fukuda K, Kai H, Kamouchi M, Hata J, Ago T, Nakane H, Imaizumi T, Kitazono T, Ishitsuka T, Fujimoto S, Ibayashi S, Kusuda K, Arakawa S, Irie K, Fujii K, Okada Y, Yasaka M, Nagao T, Ooboshi H, Omae T, Toyoda K, Sugimori H, Kuroda J, Wakisaka Y, Matsuo R, Fukushima Y. Day-by-Day Blood Pressure Variability and Functional Outcome After Acute Ischemic Stroke. Stroke 2015; 46:1832-9. [DOI: 10.1161/strokeaha.115.009076] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 05/18/2015] [Indexed: 12/31/2022]
Abstract
Background and Purpose—
The relationship between blood pressure (BP) variability and functional outcome in patients with acute ischemic stroke remains unclear. This study aimed to elucidate whether in-hospital day-by-day BP variability is associated with functional outcome after acute ischemic stroke.
Methods—
Using the Fukuoka Stroke Registry, we included 2566 patients with a first-ever ischemic stroke who had been functionally independent before the onset and were hospitalized within 24 hours. BP was measured daily, and its variability was assessed by SD, coefficients of variance, and variations independent of mean. Poor functional outcome was assessed by modified Rankin Scale scores ≥3 at 3 months.
Results—
After adjustment for multiple confounding factors including age, sex, risk factors, stroke features, baseline severity, thrombolytic therapy, antihypertensive agents, and mean BP, day-by-day BP variability during the subacute stage (4–10 days after onset) was independently associated with a poor functional outcome (multivariable-adjusted odds ratios [95% confidence interval] in the top versus bottom quartile of systolic BP variability, 1.51 [1.09–2.08] for SD; 1.63 [1.20–2.22] for coefficients of variance; 1.64 [1.21–2.24] for variations independent of mean). Similar trends were also observed for diastolic BP variability. These trends were unchanged in patients who were not treated with antihypertensive drugs. In contrast, no association was found between indices of BP variability during the acute stage and functional outcome after adjusting for potential confounders.
Conclusions—
These data suggest that intraindividual day-by-day BP variability during the subacute stage is associated with the 3-month functional outcome after acute ischemic stroke.
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Affiliation(s)
- Kenji Fukuda
- From the Department of Medicine and Clinical Science, Graduate School of Medical Sciences (K.F., J.H., T.A., T.K.), Department of Health Care Administration and Management, Graduate School of Medical Sciences (M.K.), and Center for Cohort Studies, Graduate School of Medical Sciences (M.K., J.H., T.K.), Kyushu University, Fukuoka, Japan; Department of Cerebrovascular Disease, St. Mary’s Hospital, Kurume, Japan (K.F.); Department of Internal Medicine, Division of Cardio-Vascular Medicine, Kurume
| | - Hisashi Kai
- From the Department of Medicine and Clinical Science, Graduate School of Medical Sciences (K.F., J.H., T.A., T.K.), Department of Health Care Administration and Management, Graduate School of Medical Sciences (M.K.), and Center for Cohort Studies, Graduate School of Medical Sciences (M.K., J.H., T.K.), Kyushu University, Fukuoka, Japan; Department of Cerebrovascular Disease, St. Mary’s Hospital, Kurume, Japan (K.F.); Department of Internal Medicine, Division of Cardio-Vascular Medicine, Kurume
| | - Masahiro Kamouchi
- From the Department of Medicine and Clinical Science, Graduate School of Medical Sciences (K.F., J.H., T.A., T.K.), Department of Health Care Administration and Management, Graduate School of Medical Sciences (M.K.), and Center for Cohort Studies, Graduate School of Medical Sciences (M.K., J.H., T.K.), Kyushu University, Fukuoka, Japan; Department of Cerebrovascular Disease, St. Mary’s Hospital, Kurume, Japan (K.F.); Department of Internal Medicine, Division of Cardio-Vascular Medicine, Kurume
| | - Jun Hata
- From the Department of Medicine and Clinical Science, Graduate School of Medical Sciences (K.F., J.H., T.A., T.K.), Department of Health Care Administration and Management, Graduate School of Medical Sciences (M.K.), and Center for Cohort Studies, Graduate School of Medical Sciences (M.K., J.H., T.K.), Kyushu University, Fukuoka, Japan; Department of Cerebrovascular Disease, St. Mary’s Hospital, Kurume, Japan (K.F.); Department of Internal Medicine, Division of Cardio-Vascular Medicine, Kurume
| | - Tetsuro Ago
- From the Department of Medicine and Clinical Science, Graduate School of Medical Sciences (K.F., J.H., T.A., T.K.), Department of Health Care Administration and Management, Graduate School of Medical Sciences (M.K.), and Center for Cohort Studies, Graduate School of Medical Sciences (M.K., J.H., T.K.), Kyushu University, Fukuoka, Japan; Department of Cerebrovascular Disease, St. Mary’s Hospital, Kurume, Japan (K.F.); Department of Internal Medicine, Division of Cardio-Vascular Medicine, Kurume
| | - Hiroshi Nakane
- From the Department of Medicine and Clinical Science, Graduate School of Medical Sciences (K.F., J.H., T.A., T.K.), Department of Health Care Administration and Management, Graduate School of Medical Sciences (M.K.), and Center for Cohort Studies, Graduate School of Medical Sciences (M.K., J.H., T.K.), Kyushu University, Fukuoka, Japan; Department of Cerebrovascular Disease, St. Mary’s Hospital, Kurume, Japan (K.F.); Department of Internal Medicine, Division of Cardio-Vascular Medicine, Kurume
| | - Tsutomu Imaizumi
- From the Department of Medicine and Clinical Science, Graduate School of Medical Sciences (K.F., J.H., T.A., T.K.), Department of Health Care Administration and Management, Graduate School of Medical Sciences (M.K.), and Center for Cohort Studies, Graduate School of Medical Sciences (M.K., J.H., T.K.), Kyushu University, Fukuoka, Japan; Department of Cerebrovascular Disease, St. Mary’s Hospital, Kurume, Japan (K.F.); Department of Internal Medicine, Division of Cardio-Vascular Medicine, Kurume
| | - Takanari Kitazono
- From the Department of Medicine and Clinical Science, Graduate School of Medical Sciences (K.F., J.H., T.A., T.K.), Department of Health Care Administration and Management, Graduate School of Medical Sciences (M.K.), and Center for Cohort Studies, Graduate School of Medical Sciences (M.K., J.H., T.K.), Kyushu University, Fukuoka, Japan; Department of Cerebrovascular Disease, St. Mary’s Hospital, Kurume, Japan (K.F.); Department of Internal Medicine, Division of Cardio-Vascular Medicine, Kurume
| | | | | | | | | | - Shuji Arakawa
- Japan Labour Health and Welfare Organization Kyushu Rosai Hospital
| | | | | | - Yasushi Okada
- National Hospital Organization Kyushu Medical Center
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24
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Sandset EC, Jusufovic M, Sandset PM, Bath PM, Berge E. Effects of Blood Pressure–Lowering Treatment in Different Subtypes of Acute Ischemic Stroke. Stroke 2015; 46:877-9. [DOI: 10.1161/strokeaha.114.008512] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Else Charlotte Sandset
- From the Department of Neurology (E.C.S., M.J.), Department of Haematology (P.M.S.), and Department of Internal Medicine (E.B.), Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway (P.M.S.); and Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.W.B.)
| | - Mirza Jusufovic
- From the Department of Neurology (E.C.S., M.J.), Department of Haematology (P.M.S.), and Department of Internal Medicine (E.B.), Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway (P.M.S.); and Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.W.B.)
| | - Per Morten Sandset
- From the Department of Neurology (E.C.S., M.J.), Department of Haematology (P.M.S.), and Department of Internal Medicine (E.B.), Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway (P.M.S.); and Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.W.B.)
| | - Philip M.W. Bath
- From the Department of Neurology (E.C.S., M.J.), Department of Haematology (P.M.S.), and Department of Internal Medicine (E.B.), Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway (P.M.S.); and Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.W.B.)
| | - Eivind Berge
- From the Department of Neurology (E.C.S., M.J.), Department of Haematology (P.M.S.), and Department of Internal Medicine (E.B.), Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway (P.M.S.); and Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.W.B.)
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25
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Jensen MB, Yoo B, Clarke WR, Davis PH, Adams HR. Blood Pressure as an Independent Prognostic Factor in Acute Ischemic Stroke. Can J Neurol Sci 2014; 33:34-8. [PMID: 16583719 DOI: 10.1017/s0317167100004662] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND PURPOSE Blood pressure is elevated in most patients during acute ischemic stroke, but the prognostic significance of this is unclear as the current data yield conflicting results. METHODS Admission blood pressure from the 1281 patients in the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) was analyzed for prognostic significance as well as the risk of hemorrhagic transformation. We also examined weighted-average blood pressure over seven days, and the impact of a 30% change in blood pressure in 24 hours. Patients with severe hypertension were excluded from the TOAST trial. RESULTS Increasing systolic blood pressure (SBP) on admission, but not diastolic (DBP) or mean arterial pressure (MAP) was predictive of poor outcome, but this effect was not significant after adjustment for other know prognostic factors. Increasing weighted-average SBP and MAP over seven days were predictive for poor outcome, but a 30% change in blood pressure over 24 hours was not. CONCLUSIONS Admission blood pressure is not an independent prognostic factor in acute ischemic stroke, but the weighted-average of SBP and MAP over seven days probably does have predictive value with higher values having a worse prognosis. A prospective trial of blood pressure control during acute stroke is needed.
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Affiliation(s)
- Matt B Jensen
- Stroke Center, University of California, San Diego, CA 92103-8466, USA
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26
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Doğan NÖ, Akıncı E, Gümüş H, Akıllı NB, Aksel G. Predictors of Inhospital Mortality in Geriatric Patients Presenting to the Emergency Department With Ischemic Stroke. Clin Appl Thromb Hemost 2014; 22:280-4. [PMID: 25228671 DOI: 10.1177/1076029614550820] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
AIM To determine the most important predictors of inhospital mortality that could be assessed in geriatric patients presenting with ischemic stroke at admission to the emergency department(ED). METHODS A retrospective cohort study was carried out in geriatric patients with ischemic stroke who were diagnosed in the ED. The primary outcome measure was determined as all-cause inhospital mortality after 30 days of ischemic cerebrovascular event. RESULTS During the study period, 247 (35.7%) patients died in the hospital and 445 (64.3%) patients survived the 30-day period. The median age of the patients was 78 (72-83). Higher National Institutes of Health Stroke Scale (NIHSS) scores (odds ratio [OR]: 2.085; 95% confidence interval [CI]: 1.835-2.370), increased creatinine levels (OR: 2.002; 95% CI: 1.235-3.243), increased platelet levels (OR:1.006; 95% CI: 1.002-1.010), and hyperglycemia (OR: 2.610; 95% CI: 1.023-6.660) were found as independent predictors of inhospital mortality. CONCLUSION In evaluating geriatric patients with ischemic stroke, laboratory values including platelet count, creatinine levels, hyperglycemia, and NIHSS scores should be considered to predict inhospital mortality in the ED.
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Affiliation(s)
| | - Emine Akıncı
- Department of Emergency Medicine, Keçiören Training and Research Hospital, Ankara, Turkey
| | - Haluk Gümüş
- Department of Neurology, Konya Training and Research Hospital, Konya, Turkey
| | - Nazire Belgin Akıllı
- Department of Emergency Medicine, Konya Training and Research Hospital, Konya, Turkey
| | - Gökhan Aksel
- Department of Emergency Medicine, Ümraniye Training and Research Hospital, İstanbul, Turkey
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27
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Ishitsuka K, Kamouchi M, Hata J, Fukuda K, Matsuo R, Kuroda J, Ago T, Kuwashiro T, Sugimori H, Nakane H, Kitazono T. High Blood Pressure After Acute Ischemic Stroke Is Associated With Poor Clinical Outcomes. Hypertension 2014; 63:54-60. [DOI: 10.1161/hypertensionaha.113.02189] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The relationship between the poststroke blood pressure (BP) and functional outcomes in patients with acute ischemic stroke is still controversial. The aim of the present study was to elucidate the impact of the poststroke BP on the clinical outcomes of acute ischemic stroke. Among the patients in the Fukuoka Stroke Registry, 1874 patients with first-ever acute ischemic stroke (within 24 hours of onset) who had been functionally independent before onset were prospectively enrolled in the present study. The poststroke BP levels were defined as the average values during the 48 hours after onset. The study outcomes were a good neurological recovery, neurological deterioration, and a poor functional outcome. The higher poststroke BP levels were significantly associated with a lower probability of a good neurological recovery and elevated risks of neurological deterioration and a poor functional outcome after adjusting for potential confounding factors. The multivariate-adjusted odds ratios (95% confidence interval) in the highest quintile of systolic BP (versus the lowest quintile as a reference) were 0.51 (0.37–0.71) for a good neurological recovery, 1.92 (1.15–3.27) for neurological deterioration, and 2.51 (1.69–3.74) for a poor functional outcome. Similar associations were observed when we applied the poststroke diastolic BP or pulse pressure. No evidence of the J-curve phenomenon was observed for each association. These results suggest that a high poststroke BP was significantly associated with unfavorable clinical outcomes in patients with acute ischemic stroke. There was no evidence of the J-curve phenomenon between the poststroke BP levels and the clinical outcomes.
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Affiliation(s)
- Koji Ishitsuka
- From the Departments of Medicine and Clinical Science (K.I., R.M., J.K., T.A., T.K., H.S., T.K.), Health Care Administration and Management (M.K.), and Environmental Medicine (J.H.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Nephrology, Hypertension, and Strokology (K.I., M.K., J.H., J.K., T.A., T.K.), Emergency and Critical Care Center (T.K., H.S.), Kyushu University Hospital, Fukuoka, Japan; Division of Cardio-Vascular Medicine, Department of Internal
| | - Masahiro Kamouchi
- From the Departments of Medicine and Clinical Science (K.I., R.M., J.K., T.A., T.K., H.S., T.K.), Health Care Administration and Management (M.K.), and Environmental Medicine (J.H.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Nephrology, Hypertension, and Strokology (K.I., M.K., J.H., J.K., T.A., T.K.), Emergency and Critical Care Center (T.K., H.S.), Kyushu University Hospital, Fukuoka, Japan; Division of Cardio-Vascular Medicine, Department of Internal
| | - Jun Hata
- From the Departments of Medicine and Clinical Science (K.I., R.M., J.K., T.A., T.K., H.S., T.K.), Health Care Administration and Management (M.K.), and Environmental Medicine (J.H.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Nephrology, Hypertension, and Strokology (K.I., M.K., J.H., J.K., T.A., T.K.), Emergency and Critical Care Center (T.K., H.S.), Kyushu University Hospital, Fukuoka, Japan; Division of Cardio-Vascular Medicine, Department of Internal
| | - Kenji Fukuda
- From the Departments of Medicine and Clinical Science (K.I., R.M., J.K., T.A., T.K., H.S., T.K.), Health Care Administration and Management (M.K.), and Environmental Medicine (J.H.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Nephrology, Hypertension, and Strokology (K.I., M.K., J.H., J.K., T.A., T.K.), Emergency and Critical Care Center (T.K., H.S.), Kyushu University Hospital, Fukuoka, Japan; Division of Cardio-Vascular Medicine, Department of Internal
| | - Ryu Matsuo
- From the Departments of Medicine and Clinical Science (K.I., R.M., J.K., T.A., T.K., H.S., T.K.), Health Care Administration and Management (M.K.), and Environmental Medicine (J.H.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Nephrology, Hypertension, and Strokology (K.I., M.K., J.H., J.K., T.A., T.K.), Emergency and Critical Care Center (T.K., H.S.), Kyushu University Hospital, Fukuoka, Japan; Division of Cardio-Vascular Medicine, Department of Internal
| | - Junya Kuroda
- From the Departments of Medicine and Clinical Science (K.I., R.M., J.K., T.A., T.K., H.S., T.K.), Health Care Administration and Management (M.K.), and Environmental Medicine (J.H.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Nephrology, Hypertension, and Strokology (K.I., M.K., J.H., J.K., T.A., T.K.), Emergency and Critical Care Center (T.K., H.S.), Kyushu University Hospital, Fukuoka, Japan; Division of Cardio-Vascular Medicine, Department of Internal
| | - Tetsuro Ago
- From the Departments of Medicine and Clinical Science (K.I., R.M., J.K., T.A., T.K., H.S., T.K.), Health Care Administration and Management (M.K.), and Environmental Medicine (J.H.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Nephrology, Hypertension, and Strokology (K.I., M.K., J.H., J.K., T.A., T.K.), Emergency and Critical Care Center (T.K., H.S.), Kyushu University Hospital, Fukuoka, Japan; Division of Cardio-Vascular Medicine, Department of Internal
| | - Takahiro Kuwashiro
- From the Departments of Medicine and Clinical Science (K.I., R.M., J.K., T.A., T.K., H.S., T.K.), Health Care Administration and Management (M.K.), and Environmental Medicine (J.H.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Nephrology, Hypertension, and Strokology (K.I., M.K., J.H., J.K., T.A., T.K.), Emergency and Critical Care Center (T.K., H.S.), Kyushu University Hospital, Fukuoka, Japan; Division of Cardio-Vascular Medicine, Department of Internal
| | - Hiroshi Sugimori
- From the Departments of Medicine and Clinical Science (K.I., R.M., J.K., T.A., T.K., H.S., T.K.), Health Care Administration and Management (M.K.), and Environmental Medicine (J.H.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Nephrology, Hypertension, and Strokology (K.I., M.K., J.H., J.K., T.A., T.K.), Emergency and Critical Care Center (T.K., H.S.), Kyushu University Hospital, Fukuoka, Japan; Division of Cardio-Vascular Medicine, Department of Internal
| | - Hiroshi Nakane
- From the Departments of Medicine and Clinical Science (K.I., R.M., J.K., T.A., T.K., H.S., T.K.), Health Care Administration and Management (M.K.), and Environmental Medicine (J.H.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Nephrology, Hypertension, and Strokology (K.I., M.K., J.H., J.K., T.A., T.K.), Emergency and Critical Care Center (T.K., H.S.), Kyushu University Hospital, Fukuoka, Japan; Division of Cardio-Vascular Medicine, Department of Internal
| | - Takanari Kitazono
- From the Departments of Medicine and Clinical Science (K.I., R.M., J.K., T.A., T.K., H.S., T.K.), Health Care Administration and Management (M.K.), and Environmental Medicine (J.H.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Nephrology, Hypertension, and Strokology (K.I., M.K., J.H., J.K., T.A., T.K.), Emergency and Critical Care Center (T.K., H.S.), Kyushu University Hospital, Fukuoka, Japan; Division of Cardio-Vascular Medicine, Department of Internal
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Does the admission blood pressure associate with short- and long term outcome in stroke patients treated with thrombolysis? A single centre study. Int J Hypertens 2013; 2013:610353. [PMID: 23984049 PMCID: PMC3747436 DOI: 10.1155/2013/610353] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Revised: 06/03/2013] [Accepted: 06/18/2013] [Indexed: 11/18/2022] Open
Abstract
Background. The association between outcome and elevated admission blood pressure (BP) remains uncertain in acute stroke patients. The aim of the present study was to examine the association between admission blood pressure and outcome in ischemic stroke patients treated with tissue plasminogen activator (tPA). Method. This study included patients treated with tPA within 4.5 hours after symptom onset. Four quartiles based on the admission BP values were defined. BP development of the first 12 hours was compared to outcome parameters defined as NIHSS 24 hours after tPA and mRS after 3 months. Results. 265 patients were included. A trend with worse short- and long-term outcome was present in the quartiles with the lowest and highest admission BP compared to the quartile with admission values at 140–160 mm Hg systolic. BP in quartile 1 was insignificantly decreased after 12 hours while the BP in quartiles 3 and 4 remained above recommended levels. Conclusion. Admission BP is associated with short- and long-term outcome after stroke. Low- or high-admission BP indicates cardiac comorbidity or preexisting hypertension, where close monitoring and further examinations are requested to prevent poorer outcome.
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29
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Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJB, Demaerschalk BM, Khatri P, McMullan PW, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013; 44:870-947. [PMID: 23370205 DOI: 10.1161/str.0b013e318284056a] [Citation(s) in RCA: 3203] [Impact Index Per Article: 291.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators responsible for the care of acute ischemic stroke patients within the first 48 hours from stroke onset. These guidelines supersede the prior 2007 guidelines and 2009 updates. METHODS Members of the writing committee were appointed by the American Stroke Association Stroke Council's Scientific Statement Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Panel members were assigned topics relevant to their areas of expertise, reviewed the stroke literature with emphasis on publications since the prior guidelines, and drafted recommendations in accordance with the American Heart Association Stroke Council's Level of Evidence grading algorithm. RESULTS The goal of these guidelines is to limit the morbidity and mortality associated with stroke. The guidelines support the overarching concept of stroke systems of care and detail aspects of stroke care from patient recognition; emergency medical services activation, transport, and triage; through the initial hours in the emergency department and stroke unit. The guideline discusses early stroke evaluation and general medical care, as well as ischemic stroke, specific interventions such as reperfusion strategies, and general physiological optimization for cerebral resuscitation. CONCLUSIONS Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke remains urgently needed.
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30
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Ryu WS, Kim CK, Kim BJ, Lee SH. Serum uric acid levels and cerebral microbleeds in patients with acute ischemic stroke. PLoS One 2013; 8:e55210. [PMID: 23372838 PMCID: PMC3555938 DOI: 10.1371/journal.pone.0055210] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Accepted: 12/22/2012] [Indexed: 11/19/2022] Open
Abstract
Unlike experimental studies indicating a neuroprotective property of uric acid, clinical studies have shown that elevated levels of uric acid are associated with a risk of ischemic stroke. However, the association of uric acid with cerebral hemorrhage has seldom been tested. We aimed to elucidate the association between uric acid and cerebral microbleeds (CMBs), a hemorrhage-prone cerebral microangiopathy. Seven hundred twenty-four patients with ischemic stroke who were consecutively admitted to our hospital were included in this study. We collected demographic, clinical, and laboratory data, including uric acid level, and examined the presence of CMBs using T2*-weighted gradient-echo MRI. We used logistic regression analysis to examine an independent association between uric acid and CMBs. Two-hundred twenty-six patients had CMBs (31.2%). After adjusting for possible confounders, elevated uric acid was independently associated with the presence of CMBs (the highest quartile vs. lowest quartile, adjusted odd ratio [OR], 1.98; 95% confidence interval [CI], 1.16–3.39). This association retained in patients with deep or infratentorial CMBs (with or without lobar CMBs) but not among those with lobar CMBs. In addition, this association was robust among patients with hypertension (the highest quartile vs. lowest quartile, adjusted OR, 2.74; 95% CI, 1.43–5.24). In contrast, we did not find the association in patients without hypertension. We demonstrated that serum uric acid is independently associated with the presence of CMBs. In particular, the relation between uric acid and CMBs was robust in hypertensive patients.
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Affiliation(s)
- Wi-Sun Ryu
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
- Clinical Research Center for Stroke, Clinical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Chi Kyung Kim
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
- Clinical Research Center for Stroke, Clinical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Beom Joon Kim
- Department of Neurology, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Seung-Hoon Lee
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
- Clinical Research Center for Stroke, Clinical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
- * E-mail:
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Kang J, Ko Y, Park JH, Kim WJ, Jang MS, Yang MH, Lee J, Lee J, Han MK, Gorelick PB, Bae HJ. Effect of blood pressure on 3-month functional outcome in the subacute stage of ischemic stroke. Neurology 2012; 79:2018-24. [PMID: 23054228 DOI: 10.1212/wnl.0b013e3182749eb8] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE We aimed to study various measures of blood pressure (BP) in the subacute phase of ischemic stroke to determine whether any of them predicted clinical outcome. METHODS In this retrospective observational study, a consecutive series of patients hospitalized for ischemic stroke within 48 hours of onset were enrolled. The subacute stage of stroke was defined as the time period from 72 hours of symptom onset to discharge or transfer. During this period, mean, maximum, maximum - minimum, SD, and coefficient of variation of systolic BP (SBP) and diastolic BP (DBP) were determined. A baseline severity-adjusted analysis was performed using each patient's 3-month modified Rankin Scale score as the primary outcome. RESULTS Among a total of 2,271 patients, the median number of BP measurements was 34 per person and the median interval from onset to discharge was 8.7 days. Measures of variability of BP were associated with poor outcome. One SD increase of maximum - minimum (odds ratio [OR], 1.26; 95% confidence interval [CI], 1.12-1.42), SD (OR, 1.20; 95% CI, 1.07-1.34), or coefficient of variation (OR, 1.21; 95% CI, 1.09-1.35) for SBP, but not mean level of SBP (OR, 0.92; 95% CI, 0.79-1.07), was independently associated with poor outcome. Results were similar for DBP. CONCLUSION This study shows that variability of BP, but not average BP in the subacute stage of ischemic stroke, is associated with functional outcome at 3 months after stroke onset.
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Affiliation(s)
- Jihoon Kang
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University, Seoul, Korea
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Sandset EC, Murray GD, Bath PM, Kjeldsen SE, Berge E. Relation Between Change in Blood Pressure in Acute Stroke and Risk of Early Adverse Events and Poor Outcome. Stroke 2012; 43:2108-14. [DOI: 10.1161/strokeaha.111.647362] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
The Scandinavian Candesartan Acute Stroke Trial (SCAST) found no benefits of candesartan in acute stroke. In the present analysis we aim to investigate the effect of change in blood pressure during the first 2 days of stroke on the risk of early adverse events and poor outcome.
Methods—
SCAST was a multicenter, randomized controlled, double-blind trial of candesartan in acute stroke. The trial recruited 2029 patients presenting within 30 hours of acute stroke and with systolic blood pressure (SBP) ≥140 mm Hg. Treatment was given for 7 days. Change in blood pressure was defined as the difference in SBP between baseline and Day 2 and was used to divide patients into groups with increase/no change, a small decrease, moderate decrease, or large decrease in SBP. The primary effect parameter was early adverse events (recurrent stroke, stroke progression, and symptomatic hypotension) during the first 7 days, analyzed using logistic regression, with the group with a small decrease in SBP as the reference group. Secondary effect parameters were neurological status at 7 days and functional outcome at 6 months.
Results—
Patients with a large decrease or increase/no change in SBP had a significantly increased risk of early adverse events relative to patients with a small decrease (OR, 2.08; 95% CI, 1.19–3.65 and OR, 1.96; 95% CI, 1.13–3.38, respectively). Patients with an increase/no change in SBP had a significantly increased risk of poor neurological outcome as compared with the other groups (
P
=0.001). No differences were observed in functional outcome at 6 months.
Conclusions—
Our findings support the suggestion from SCAST that blood pressure reduction may be harmful and that routine blood pressure-lowering treatment should probably be avoided in the acute phase.
Clinical Trial Information—
Clinical Trial Registration:
www.clinicaltrials.gov
. Unique identifier: NCT00120003.
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Affiliation(s)
- Else C. Sandset
- From the Departments of Hematology and Neurology (E.C.S.) and Cardiology (S.E.K., E.B.), Oslo University Hospital Ullevål, Oslo, Norway; the Institute of Clinical Medicine, University of Oslo, Oslo, Norway (E.C.S., S.E.K.); the Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK (G.D.M.); and the Stroke Trials Unit, Division of Stroke, University of Nottingham, Nottingham, UK (P.M.W.B.)
| | - Gordon D. Murray
- From the Departments of Hematology and Neurology (E.C.S.) and Cardiology (S.E.K., E.B.), Oslo University Hospital Ullevål, Oslo, Norway; the Institute of Clinical Medicine, University of Oslo, Oslo, Norway (E.C.S., S.E.K.); the Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK (G.D.M.); and the Stroke Trials Unit, Division of Stroke, University of Nottingham, Nottingham, UK (P.M.W.B.)
| | - Philip M.W. Bath
- From the Departments of Hematology and Neurology (E.C.S.) and Cardiology (S.E.K., E.B.), Oslo University Hospital Ullevål, Oslo, Norway; the Institute of Clinical Medicine, University of Oslo, Oslo, Norway (E.C.S., S.E.K.); the Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK (G.D.M.); and the Stroke Trials Unit, Division of Stroke, University of Nottingham, Nottingham, UK (P.M.W.B.)
| | - Sverre E. Kjeldsen
- From the Departments of Hematology and Neurology (E.C.S.) and Cardiology (S.E.K., E.B.), Oslo University Hospital Ullevål, Oslo, Norway; the Institute of Clinical Medicine, University of Oslo, Oslo, Norway (E.C.S., S.E.K.); the Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK (G.D.M.); and the Stroke Trials Unit, Division of Stroke, University of Nottingham, Nottingham, UK (P.M.W.B.)
| | - Eivind Berge
- From the Departments of Hematology and Neurology (E.C.S.) and Cardiology (S.E.K., E.B.), Oslo University Hospital Ullevål, Oslo, Norway; the Institute of Clinical Medicine, University of Oslo, Oslo, Norway (E.C.S., S.E.K.); the Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK (G.D.M.); and the Stroke Trials Unit, Division of Stroke, University of Nottingham, Nottingham, UK (P.M.W.B.)
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Soares I, Abecasis P, Ferro JM. Outcome of first-ever acute ischemic stroke in the elderly. Arch Gerontol Geriatr 2011; 53:e81-7. [DOI: 10.1016/j.archger.2010.06.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2010] [Revised: 06/25/2010] [Accepted: 06/27/2010] [Indexed: 11/15/2022]
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Rossi P, Mandelli C, Manganaro D, Zecca B, Maestroni A, Monzani V, Torgano G. A spontaneous decrease of blood pressure occurs in acute ischemic stroke with favourable neurological course. Open Neurol J 2011; 5:48-54. [PMID: 21760858 PMCID: PMC3134949 DOI: 10.2174/1874205x01105010048] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2010] [Revised: 02/01/2011] [Accepted: 02/01/2011] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In the acute phase of ischemic stroke the relationship between blood pressure (BP) and clinical outcome remains not clear. The aim of our study was to evaluate the association of stroke severity and BP measurements in the acute phase of stroke, and whether early variation of neurological status affects BP profiles. METHODS BP on admission was obtained with mercurial sphygmomanometer and 24h-ambulatory BP monitoring (ABPM) was performed on days 1(st) and 6(th). Enrolled patient were grouped according to the neurological deficit at onset (graded by the NIHSS) in group A, (NIHSS score ≤ 10, mild/moderate) and group B (NIHSS score > 10, moderate/severe) and according to the occurrence of early neurological improvement, defined as a NIHSS score reduction of at least 4 points at the 6(th) day in group C (improved) and in group D (not improved). RESULTS A total of 57 patients were enrolled. On admission sphygmomanometric systolic BP values were higher in group A with respect to group B (158,5 mmHg ± 26,9 vs 147,7 mmHg ± 15,5 respectively; p = 0.6) whereas no difference was found in ABPM. On admission sphygmomanometric BP and ABPM were similar in group C and group D. At the 6(th) day ABPM, both systolic BP and diastolic BP values were significantly reduced in clinically improved patients (Δ systolic BP 1(st) to 6(th) day = 9,9±13,3 in group C vs 0,5±17,6 in group D, p < 0,05; Δ diastolic BP 1(st) to 6(th) day = 5,1± 8,4 mmHg in group C vs 1,3 ± 9,7 mmHg in group D, p = ns) whereas no change in the 24-h BP profile was observed in patients without early improvement. CONCLUSION BP on admission in not related to the stroke severity and does not predict early neurological outcome and patients that show an early neurological improvement show also a reduction of the BP profile.
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Affiliation(s)
| | | | | | | | | | | | - G Torgano
- Department of Emergency Medicine, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milano, Itlay
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Geeganage C, Tracy M, England T, Sare G, Moulin T, Woimant F, Christensen H, De Deyn PP, Leys D, O'Neill D, Ringelstein EB, Bath PM. Relationship Between Baseline Blood Pressure Parameters (Including Mean Pressure, Pulse Pressure, and Variability) and Early Outcome After Stroke. Stroke 2011; 42:491-3. [DOI: 10.1161/strokeaha.110.596163] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Chamila Geeganage
- From the University of Nottingham (C.G., M.T., T.E., G.S., P.M.W.B.), Nottingham, United Kingdom; University of Franche-Comté (T.M.), Besançon, France; Lariboisiere University Hospital (F.W.), Paris, France; University of Copenhagen (H.C.), Copenhagen, Denmark; University of Antwerp (P.P.D.), Antwerp, Belgium; CHRU de Lille (D.L.), Lille, France; Adelaide & Meath Hospital (D.O.), Dublin, Ireland; University of Münster (E.B.R.), Münster, Germany
| | - Michael Tracy
- From the University of Nottingham (C.G., M.T., T.E., G.S., P.M.W.B.), Nottingham, United Kingdom; University of Franche-Comté (T.M.), Besançon, France; Lariboisiere University Hospital (F.W.), Paris, France; University of Copenhagen (H.C.), Copenhagen, Denmark; University of Antwerp (P.P.D.), Antwerp, Belgium; CHRU de Lille (D.L.), Lille, France; Adelaide & Meath Hospital (D.O.), Dublin, Ireland; University of Münster (E.B.R.), Münster, Germany
| | - Timothy England
- From the University of Nottingham (C.G., M.T., T.E., G.S., P.M.W.B.), Nottingham, United Kingdom; University of Franche-Comté (T.M.), Besançon, France; Lariboisiere University Hospital (F.W.), Paris, France; University of Copenhagen (H.C.), Copenhagen, Denmark; University of Antwerp (P.P.D.), Antwerp, Belgium; CHRU de Lille (D.L.), Lille, France; Adelaide & Meath Hospital (D.O.), Dublin, Ireland; University of Münster (E.B.R.), Münster, Germany
| | - Gillian Sare
- From the University of Nottingham (C.G., M.T., T.E., G.S., P.M.W.B.), Nottingham, United Kingdom; University of Franche-Comté (T.M.), Besançon, France; Lariboisiere University Hospital (F.W.), Paris, France; University of Copenhagen (H.C.), Copenhagen, Denmark; University of Antwerp (P.P.D.), Antwerp, Belgium; CHRU de Lille (D.L.), Lille, France; Adelaide & Meath Hospital (D.O.), Dublin, Ireland; University of Münster (E.B.R.), Münster, Germany
| | - Thierry Moulin
- From the University of Nottingham (C.G., M.T., T.E., G.S., P.M.W.B.), Nottingham, United Kingdom; University of Franche-Comté (T.M.), Besançon, France; Lariboisiere University Hospital (F.W.), Paris, France; University of Copenhagen (H.C.), Copenhagen, Denmark; University of Antwerp (P.P.D.), Antwerp, Belgium; CHRU de Lille (D.L.), Lille, France; Adelaide & Meath Hospital (D.O.), Dublin, Ireland; University of Münster (E.B.R.), Münster, Germany
| | - France Woimant
- From the University of Nottingham (C.G., M.T., T.E., G.S., P.M.W.B.), Nottingham, United Kingdom; University of Franche-Comté (T.M.), Besançon, France; Lariboisiere University Hospital (F.W.), Paris, France; University of Copenhagen (H.C.), Copenhagen, Denmark; University of Antwerp (P.P.D.), Antwerp, Belgium; CHRU de Lille (D.L.), Lille, France; Adelaide & Meath Hospital (D.O.), Dublin, Ireland; University of Münster (E.B.R.), Münster, Germany
| | - Hanne Christensen
- From the University of Nottingham (C.G., M.T., T.E., G.S., P.M.W.B.), Nottingham, United Kingdom; University of Franche-Comté (T.M.), Besançon, France; Lariboisiere University Hospital (F.W.), Paris, France; University of Copenhagen (H.C.), Copenhagen, Denmark; University of Antwerp (P.P.D.), Antwerp, Belgium; CHRU de Lille (D.L.), Lille, France; Adelaide & Meath Hospital (D.O.), Dublin, Ireland; University of Münster (E.B.R.), Münster, Germany
| | - Peter Paul De Deyn
- From the University of Nottingham (C.G., M.T., T.E., G.S., P.M.W.B.), Nottingham, United Kingdom; University of Franche-Comté (T.M.), Besançon, France; Lariboisiere University Hospital (F.W.), Paris, France; University of Copenhagen (H.C.), Copenhagen, Denmark; University of Antwerp (P.P.D.), Antwerp, Belgium; CHRU de Lille (D.L.), Lille, France; Adelaide & Meath Hospital (D.O.), Dublin, Ireland; University of Münster (E.B.R.), Münster, Germany
| | - Didier Leys
- From the University of Nottingham (C.G., M.T., T.E., G.S., P.M.W.B.), Nottingham, United Kingdom; University of Franche-Comté (T.M.), Besançon, France; Lariboisiere University Hospital (F.W.), Paris, France; University of Copenhagen (H.C.), Copenhagen, Denmark; University of Antwerp (P.P.D.), Antwerp, Belgium; CHRU de Lille (D.L.), Lille, France; Adelaide & Meath Hospital (D.O.), Dublin, Ireland; University of Münster (E.B.R.), Münster, Germany
| | - Desmond O'Neill
- From the University of Nottingham (C.G., M.T., T.E., G.S., P.M.W.B.), Nottingham, United Kingdom; University of Franche-Comté (T.M.), Besançon, France; Lariboisiere University Hospital (F.W.), Paris, France; University of Copenhagen (H.C.), Copenhagen, Denmark; University of Antwerp (P.P.D.), Antwerp, Belgium; CHRU de Lille (D.L.), Lille, France; Adelaide & Meath Hospital (D.O.), Dublin, Ireland; University of Münster (E.B.R.), Münster, Germany
| | - E. Bernd Ringelstein
- From the University of Nottingham (C.G., M.T., T.E., G.S., P.M.W.B.), Nottingham, United Kingdom; University of Franche-Comté (T.M.), Besançon, France; Lariboisiere University Hospital (F.W.), Paris, France; University of Copenhagen (H.C.), Copenhagen, Denmark; University of Antwerp (P.P.D.), Antwerp, Belgium; CHRU de Lille (D.L.), Lille, France; Adelaide & Meath Hospital (D.O.), Dublin, Ireland; University of Münster (E.B.R.), Münster, Germany
| | - Philip M.W. Bath
- From the University of Nottingham (C.G., M.T., T.E., G.S., P.M.W.B.), Nottingham, United Kingdom; University of Franche-Comté (T.M.), Besançon, France; Lariboisiere University Hospital (F.W.), Paris, France; University of Copenhagen (H.C.), Copenhagen, Denmark; University of Antwerp (P.P.D.), Antwerp, Belgium; CHRU de Lille (D.L.), Lille, France; Adelaide & Meath Hospital (D.O.), Dublin, Ireland; University of Münster (E.B.R.), Münster, Germany
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Pathways to further boost treatment rates and clinical outcomes in hospitalized stroke patients. Crit Pathw Cardiol 2010; 9:8-13. [PMID: 20215904 DOI: 10.1097/hpc.0b013e3181cd5c84] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Inpatient quality improvement initiatives have been associated with impressive improvements in evidence-based discharge treatment rates in hospitalized stroke patients. However, these programs have generally focused only on optimizing recurrent stroke prevention strategies among ischemic stroke patients. Many patients hospitalized with recent symptomatic cerebral ischemia are also at risk for future ischemic episodes emanating from other vascular beds, and the inpatient setting could represent an opportunity to screen and appropriately manage such patients who harbor cross-vascular risk. The stroke hospitalization may also be ideal for identifying stroke patients susceptible to a highly preventable yet common trigger of vascular events and poor clinical outcomes like influenza infection. Finally, several hospital-based prevention measures are underutilized in patients hospitalized with intracerebral hemorrhage (ICH) compared with those with ischemic stroke or transient ischemic attack, and so protocols geared at enhancing prevention of ICH recurrence, are certainly warranted. This article presents pathways (algorithms, pocket cards, preprinted orders) developed from expert consensus prevention guidelines and implemented within a broader stroke inpatient quality improvement program, which target patients highly vulnerable to future coronary events, poor clinical outcomes following influenza infection, and recurrent ICH.
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Elevación de la presión arterial en la fase aguda del ictus. Tratar o no tratar. HIPERTENSION Y RIESGO VASCULAR 2009. [DOI: 10.1016/j.hipert.2009.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Tikhonoff V, Zhang H, Richart T, Staessen JA. Blood pressure as a prognostic factor after acute stroke. Lancet Neurol 2009; 8:938-48. [DOI: 10.1016/s1474-4422(09)70184-x] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Ovbiagele B, Liebeskind DS, Kim D, Ali LK, Pineda S, Saver JL. Optimizing screening and management of asymptomatic coronary artery disease in patients with stroke and patients with transient ischemic attack. Stroke 2009; 40:3407-9. [PMID: 19679844 DOI: 10.1161/strokeaha.109.560151] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The feasibility of implementing an expert consensus guideline recommending use of a stroke patient's profile to manage undiagnosed coronary artery disease remains unclear. METHODS Following a guideline-based algorithm, we screened consecutive patients with ischemic stroke and patients with transient ischemic attack for asymptomatic coronary artery disease using the Framingham Heart Study Coronary Risk Score (FCRS) cutoff of high risk (> or = 20%) for experiencing a hard coronary artery disease event over a 10-year period. Patients with high FCRS received dobutamine stress echocardiogram outpatient screening, additional treatment (beta-blocker), or further management (cardiologist referral). RESULTS From July 2004 to September 2007, among 693 patients, 501 (72%) met study criteria, of which 80 (16%) had FCRS > or = 20%. Elevated serum glucose, nonhigh-density lipoprotein, triglycerides, homocysteine, glycosylated hemoglobin as well as large vessel atherosclerotic stroke mechanism were more frequent in high versus low FCRS patients (P<0.05). Among high FCRS patients, 35 (44%) had dobutamine stress echocardiogram performed. Leading reasons for dobutamine stress echocardiogram nonperformance were patient noncompliance (42%) and primary care physician refusal (33%). CONCLUSIONS Screening for coronary artery disease risk using FCRS is feasible in hospitalized patients with stroke, but outpatient adherence to stress testing is challenging largely due to patient and primary care physician-related factors.
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Armario P, MartÍn‐Baranera M, Miguel Ceresuela L, Hernández Del Rey R, Iribarnegaray E, Pintado S, Avila A, Bello J, Luis Tovar J, Alvarez‐Sabin J. Blood pressure in the initial phase of acute ischaemic stroke: Evolution and its role as an independent prognosis factor at discharge and after 3 months of follow‐up. Blood Press 2009; 17:284-90. [DOI: 10.1080/08037050802565320] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Sare GM, Bath PM, Gray LJ, Moulin T, Woimant F, England T, Geeganage C, Christensen H, De Deyn PP, Leys D, O'Neill D, Ringelstein EB. The Relationship Between Baseline Blood Pressure and Computed Tomography Findings in Acute Stroke. Stroke 2009; 40:41-6. [DOI: 10.1161/strokeaha.108.526665] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
High blood pressure (BP) is present in ≈80% of patients with acute ischemic stroke and is independently associated with poor outcome. There are few data examining the relationship between admission BP and acute CT findings.
Methods—
TAIST was a randomized controlled trial assessing 10 days of treatment with tinzaparin versus aspirin in 1489 patients with acute ischemic stroke (<48 hr) with admission BP of ≤220/120 mmHg. CT brain scans were performed before randomization and after 10 days. The relationships between baseline BP and adjudicated CT findings were assessed. Odds ratios per 10 mmHg change in BP were calculated.
Results—
Higher systolic BP (SBP) was associated with abnormal CT scans because of independent associations with chronic changes of leukoariosis (OR, 1.12; 95% CI, 1.05–1.17) and old infarction (OR, 1.12; 95% CI, 1.06–1.17) at baseline, and signs of visible infarction at day 10 (OR, 1.06; 95% CI, 1.00–1.13). A lower SBP was associated with signs of acute infarction (OR, 0.94; 95% CI, 0.89–0.99). Hemorrhagic transformation, dense middle cerebral artery sign, mass effect, and cerebral edema at day 10 were not independently associated with baseline BP.
Conclusion—
Although high baseline BP is independently associated with a poor outcome after stroke, this was not shown to be through an association with increased hemorrhagic transformation, cerebral edema, or mass effect; trial design may be suboptimal to detect this. Higher SBP is associated with visible infarction on day 10 scans. The influence of changing BP in acute stroke on CT findings is still to be ascertained.
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Affiliation(s)
- Gillian M. Sare
- From Institute of Neuroscience (G.M.S., P.M.W.B., L.J.G., T.E., C.G.), University of Nottingham, Nottingham, UK; Stroke Unit (T.M.), CHU Besancon, University of Franche-Comte, Besancon, France; Department of Neurology (F.W.), Lariboisiere University Hospital, France; Department of Neurology (H.C.), Bispebjerg Hospital, Copenhagen, Denmark; Department of Neurology (P.P.D.D.), A. Z. Middelheim, ZNA, University of Antwerp, Antwerpen, Belgium; Clinique Neurologique (D.L.), CHRU de Lille, Lille, France
| | - Philip M.W. Bath
- From Institute of Neuroscience (G.M.S., P.M.W.B., L.J.G., T.E., C.G.), University of Nottingham, Nottingham, UK; Stroke Unit (T.M.), CHU Besancon, University of Franche-Comte, Besancon, France; Department of Neurology (F.W.), Lariboisiere University Hospital, France; Department of Neurology (H.C.), Bispebjerg Hospital, Copenhagen, Denmark; Department of Neurology (P.P.D.D.), A. Z. Middelheim, ZNA, University of Antwerp, Antwerpen, Belgium; Clinique Neurologique (D.L.), CHRU de Lille, Lille, France
| | - Laura J. Gray
- From Institute of Neuroscience (G.M.S., P.M.W.B., L.J.G., T.E., C.G.), University of Nottingham, Nottingham, UK; Stroke Unit (T.M.), CHU Besancon, University of Franche-Comte, Besancon, France; Department of Neurology (F.W.), Lariboisiere University Hospital, France; Department of Neurology (H.C.), Bispebjerg Hospital, Copenhagen, Denmark; Department of Neurology (P.P.D.D.), A. Z. Middelheim, ZNA, University of Antwerp, Antwerpen, Belgium; Clinique Neurologique (D.L.), CHRU de Lille, Lille, France
| | - Thierry Moulin
- From Institute of Neuroscience (G.M.S., P.M.W.B., L.J.G., T.E., C.G.), University of Nottingham, Nottingham, UK; Stroke Unit (T.M.), CHU Besancon, University of Franche-Comte, Besancon, France; Department of Neurology (F.W.), Lariboisiere University Hospital, France; Department of Neurology (H.C.), Bispebjerg Hospital, Copenhagen, Denmark; Department of Neurology (P.P.D.D.), A. Z. Middelheim, ZNA, University of Antwerp, Antwerpen, Belgium; Clinique Neurologique (D.L.), CHRU de Lille, Lille, France
| | - France Woimant
- From Institute of Neuroscience (G.M.S., P.M.W.B., L.J.G., T.E., C.G.), University of Nottingham, Nottingham, UK; Stroke Unit (T.M.), CHU Besancon, University of Franche-Comte, Besancon, France; Department of Neurology (F.W.), Lariboisiere University Hospital, France; Department of Neurology (H.C.), Bispebjerg Hospital, Copenhagen, Denmark; Department of Neurology (P.P.D.D.), A. Z. Middelheim, ZNA, University of Antwerp, Antwerpen, Belgium; Clinique Neurologique (D.L.), CHRU de Lille, Lille, France
| | - Timothy England
- From Institute of Neuroscience (G.M.S., P.M.W.B., L.J.G., T.E., C.G.), University of Nottingham, Nottingham, UK; Stroke Unit (T.M.), CHU Besancon, University of Franche-Comte, Besancon, France; Department of Neurology (F.W.), Lariboisiere University Hospital, France; Department of Neurology (H.C.), Bispebjerg Hospital, Copenhagen, Denmark; Department of Neurology (P.P.D.D.), A. Z. Middelheim, ZNA, University of Antwerp, Antwerpen, Belgium; Clinique Neurologique (D.L.), CHRU de Lille, Lille, France
| | - Chamila Geeganage
- From Institute of Neuroscience (G.M.S., P.M.W.B., L.J.G., T.E., C.G.), University of Nottingham, Nottingham, UK; Stroke Unit (T.M.), CHU Besancon, University of Franche-Comte, Besancon, France; Department of Neurology (F.W.), Lariboisiere University Hospital, France; Department of Neurology (H.C.), Bispebjerg Hospital, Copenhagen, Denmark; Department of Neurology (P.P.D.D.), A. Z. Middelheim, ZNA, University of Antwerp, Antwerpen, Belgium; Clinique Neurologique (D.L.), CHRU de Lille, Lille, France
| | - Hanne Christensen
- From Institute of Neuroscience (G.M.S., P.M.W.B., L.J.G., T.E., C.G.), University of Nottingham, Nottingham, UK; Stroke Unit (T.M.), CHU Besancon, University of Franche-Comte, Besancon, France; Department of Neurology (F.W.), Lariboisiere University Hospital, France; Department of Neurology (H.C.), Bispebjerg Hospital, Copenhagen, Denmark; Department of Neurology (P.P.D.D.), A. Z. Middelheim, ZNA, University of Antwerp, Antwerpen, Belgium; Clinique Neurologique (D.L.), CHRU de Lille, Lille, France
| | - Peter Paul De Deyn
- From Institute of Neuroscience (G.M.S., P.M.W.B., L.J.G., T.E., C.G.), University of Nottingham, Nottingham, UK; Stroke Unit (T.M.), CHU Besancon, University of Franche-Comte, Besancon, France; Department of Neurology (F.W.), Lariboisiere University Hospital, France; Department of Neurology (H.C.), Bispebjerg Hospital, Copenhagen, Denmark; Department of Neurology (P.P.D.D.), A. Z. Middelheim, ZNA, University of Antwerp, Antwerpen, Belgium; Clinique Neurologique (D.L.), CHRU de Lille, Lille, France
| | - Didier Leys
- From Institute of Neuroscience (G.M.S., P.M.W.B., L.J.G., T.E., C.G.), University of Nottingham, Nottingham, UK; Stroke Unit (T.M.), CHU Besancon, University of Franche-Comte, Besancon, France; Department of Neurology (F.W.), Lariboisiere University Hospital, France; Department of Neurology (H.C.), Bispebjerg Hospital, Copenhagen, Denmark; Department of Neurology (P.P.D.D.), A. Z. Middelheim, ZNA, University of Antwerp, Antwerpen, Belgium; Clinique Neurologique (D.L.), CHRU de Lille, Lille, France
| | - Desmond O'Neill
- From Institute of Neuroscience (G.M.S., P.M.W.B., L.J.G., T.E., C.G.), University of Nottingham, Nottingham, UK; Stroke Unit (T.M.), CHU Besancon, University of Franche-Comte, Besancon, France; Department of Neurology (F.W.), Lariboisiere University Hospital, France; Department of Neurology (H.C.), Bispebjerg Hospital, Copenhagen, Denmark; Department of Neurology (P.P.D.D.), A. Z. Middelheim, ZNA, University of Antwerp, Antwerpen, Belgium; Clinique Neurologique (D.L.), CHRU de Lille, Lille, France
| | - E. Bernd Ringelstein
- From Institute of Neuroscience (G.M.S., P.M.W.B., L.J.G., T.E., C.G.), University of Nottingham, Nottingham, UK; Stroke Unit (T.M.), CHU Besancon, University of Franche-Comte, Besancon, France; Department of Neurology (F.W.), Lariboisiere University Hospital, France; Department of Neurology (H.C.), Bispebjerg Hospital, Copenhagen, Denmark; Department of Neurology (P.P.D.D.), A. Z. Middelheim, ZNA, University of Antwerp, Antwerpen, Belgium; Clinique Neurologique (D.L.), CHRU de Lille, Lille, France
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43
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Micieli G, Cavallini A. The autonomic nervous system and ischemic stroke: a reciprocal interdependence. Clin Auton Res 2008; 18:308-17. [PMID: 18850312 DOI: 10.1007/s10286-008-0495-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2008] [Accepted: 08/05/2008] [Indexed: 11/30/2022]
Abstract
Signs and symptoms of autonomic nervous system (ANS) dysfunction are frequently reported after ischemic or haemorrhagic stroke and in many cases they exhibit peculiar patterns in relationship with the site and the extension of brain lesion. However if an ANS disorder can cause or predispose to a stroke is far from being correctly known. Evidences in favor of a pathogenetic mechanism of an ANS dysfunction are reported for myocardial infarction and such data are likely to be appropriate also for atherothrombotic type of ischemic stroke. On the other hand, it is well known that many risk factors for this pathology are strongly correlated with an altered functioning of ANS so that a reciprocal interdependence between ANS and stroke can be hypothesized. This review points to evidence the possible relationship existing between these two conditions and suggests a quite different diagnostic and therapeutic approach to both on the basis of their pathogenetic mechanisms.
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Affiliation(s)
- Giuseppe Micieli
- Neurology and Stroke Unit, IRCCS Istituto Clinico Humanitas, Via Manzoni, 56, 20089, Rozzano, MI, Italy.
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44
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Abstract
The optimal management of arterial blood pressure in the setting of an acute stroke has not been defined. Many articles have been published on this topic in the past few years, but definitive evidence from clinical trials continues to be lacking. This situation is complicated further because stroke is a heterogeneous disease. The best management of arterial blood pressure may differ, depending on the type of stroke (ischemic or hemorrhagic) and the subtype of ischemic or hemorrhagic stroke. This article reviews the relationship between arterial blood pressure and the pathophysiology specific to ischemic stroke, primary intracerebral hemorrhage, and aneurysmal subarachnoid hemorrhage, elaborating on the concept of ischemic penumbra and the role of cerebral autoregulation. The article also examines the impact of blood pressure and its management on outcome. Finally, an agenda for research in this field is outlined.
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Affiliation(s)
- Victor C Urrutia
- Cerebrovascular Division, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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45
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Yong M, Kaste M. Association of Characteristics of Blood Pressure Profiles and Stroke Outcomes in the ECASS-II Trial. Stroke 2008; 39:366-72. [DOI: 10.1161/strokeaha.107.492330] [Citation(s) in RCA: 106] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Certain characteristics of early blood pressure (BP) profiles were reported to be independent predictors of long-term outcome in the first European Cooperative Acute Stroke Study (ECASS-I) trial. The aim of the study was to find out the association of BP profiles with functional outcome, mortality, and hemorrhagic complications in the ECASS-II database.
Methods—
We studied 793 patients with acute ischemic hemispheric stroke in the ECASS-II. After randomization, BP was measured every 15 minutes during the first 2 hours, then every 30 minutes during the first 8 hours, and thereafter at 1-hour intervals up to 24 hours. Individual 0- to 24-hour BP profiles were characterized by baseline, maximum, minimum, and mean BP and successive variation of the profile. The end points were favorable outcome (modified Rankin Scale score of 0 or 1) at day 90, all-cause mortality at day 90, and hemorrhagic transformation within the first 7 days.
Results—
High baseline, maximum, mean level, and variability of systolic BP profiles were each inversely associated with favorable outcome (OR=0.84, 95% CI: 0.74 to 0.94; OR=0.82, 95% CI: 0.73 to 0.91; OR=0.81, 95% CI: 0.71 to 0.93; OR=0.57, 95% CI: 0.35 to 0.92, respectively) and associated with an increased risk of parenchymal hemorrhage within the first 7 days (OR=1.27, 95% CI: 1.07 to 1.51; OR=1.49, 95% CI: 1.27 to 1.75; OR=1.52, 95% CI: 1.23 to 1.87; OR=2.62, 95% CI: 1.40 to 4.87; respectively) in recombinant tissue plasminogen activator-treated patients. In placebo-treated patients, high maximum, mean level, and successive variation of systolic BP profiles were inversely associated with favorable outcome (OR=0.76, 95% CI: 0.66 to 0.86; OR=0.76, 95% CI: 0.65 to 0.89; OR=0.41, 95% CI: 0.22 to 0.76; respectively), although the association of baseline systolic BP and favorable outcome was not significant (OR=0.91, 95% CI: 0.80 to 1.03). No association with hemorrhagic transformation was found, even after the adjustment.
Conclusions—
The hemorrhagic transformation within the first 7 days and favorable outcome were independently associated with dynamics of BP within the first 24 hours after an acute ischemic stroke in patients treated with thrombolysis, but in placebo-treated patients, only with favorable outcome. Continuous BP monitoring is hence important for the prognosis and gives implications to optimize BP management, particularly regarding a reasonable BP level and stability.
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Affiliation(s)
- Mei Yong
- From the Department of Statistics in Medicine (M.Y.), Heinrich Heine University Hospital, Duesseldorf, Germany; and the Department of Neurology (M.K.), Helsinki University Central Hospital, Helsinki, Finland
| | - Markku Kaste
- From the Department of Statistics in Medicine (M.Y.), Heinrich Heine University Hospital, Duesseldorf, Germany; and the Department of Neurology (M.K.), Helsinki University Central Hospital, Helsinki, Finland
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46
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Keezer MR, Yu AY, Zhu B, Wolfson C, Côté R. Blood Pressure and Antihypertensive Therapy as Predictors of Early Outcome in Acute Ischemic Stroke. Cerebrovasc Dis 2008; 25:202-8. [DOI: 10.1159/000113857] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2007] [Accepted: 08/29/2007] [Indexed: 01/04/2023] Open
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Abstract
Although control of hypertension is established as an important factor in the primary and secondary prevention of stroke, management of blood pressure in the setting of acute ischemic stroke remains controversial. Given limited data, the general consensus is that there is no proven benefit to lowering blood pressure in the first hours to days after acute ischemic stroke. Instead, there is concern that relative hypotension may lead to worsening of cerebral ischemia. For many years, the use of blood pressure augmentation ("induced hypertension") has been studied in animal models and in humans as a means of maintaining or improving perfusion to ischemic brain tissue. This approach is now widely used in neurocritical care units to treat delayed neurological deficits after subarachnoid hemorrhage, but its use in ischemic stroke patients remains anecdotal. This article reviews the cerebral physiology, animal models and human studies of induced hypertension as a treatment for acute ischemic stroke. Although there has not been a large, randomized clinical trial of this treatment, the available clinical data suggests that induced hypertension can result in at least short-term neurological improvement, with an acceptable degree of safety.
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Affiliation(s)
- Robert J Wityk
- Johns Hopkins University School of Medicine, Cerebrovascular Division, Johns Hopkins Hospital, Baltimore, MD 21287, USA.
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48
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Wong AA, Davis JP, Schluter PJ, Henderson RD, O'Sullivan JD, Read SJ. The time course and determinants of blood pressure within the first 48 h after ischemic stroke. Cerebrovasc Dis 2007; 24:426-33. [PMID: 17878723 DOI: 10.1159/000108432] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2007] [Accepted: 05/22/2007] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND PURPOSE Previous research suggests that blood pressure falls acutely after ischemic stroke. We aimed to further characterize this fall with a statistical technique that allows the application of regression techniques to serial blood pressure outcome data. METHODS In a prospectively recruited ischemic stroke cohort, systolic (SBP) and diastolic (DBP) blood pressure was recorded every 4 h until 48 h after stroke. Potential determinants of blood pressure, including stroke severity and acute infection, were also recorded. Mixed effects models were used to model serial blood pressure measurements over time, adjusted for significant determinants. RESULTS In 156 patients, SBP and DBP fell by 14.9 mm Hg (95% CI 6.2-22.6 mm Hg) and 6.2 mm Hg (95% CI 1.4-10.6 mm Hg), respectively, over the first 48 h after stroke. SBP was higher in patients with premorbid hypertension, a previous history of stroke or TIA, current alcohol use, increasing age, stroke of mild to moderate severity (NIHSS 3-13) and in patients treated with antihypertensives. SBP was lower in smokers. There was a progressive rise in SBP in patients with acute infection. No factors other than time were associated with DBP. CONCLUSIONS The use of mixed effects models has identified a linear SBP and DBP fall over the first 48 h after stroke. The timing and magnitude of this fall should be accounted for in the design of future prognostic and intervention studies.
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Affiliation(s)
- Andrew A Wong
- Department of Neurology, Royal Brisbane and Women's Hospital, Herston, Australia.
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Abstract
BACKGROUND Control of hypertension is a well-established goal of primary prevention of stroke, but management of blood pressure in patients with a previous stroke or in the setting of acute stroke is complicated by the effect blood pressure changes may have on cerebral perfusion. REVIEW SUMMARY For patients with previous transient ischemic attack or chronic stroke, blood pressure reduction appears to be a safe and important facet of the secondary prevention of recurrent stroke. Less information is available concerning blood pressure management in acute stroke. Current protocols require strict blood pressure control in patients who are treated with thrombolytic therapy, to reduce the risk of hemorrhagic complications. In patients presenting with acute intracerebral hemorrhage, blood pressure reduction does not appear to cause significant reduction of cerebral blood flow, but at this time there are no studies to determine if there is a clinical benefit of acute blood pressure reduction in these patients. Finally, blood pressure reduction is not routinely recommended in patients with acute ischemic stroke, as it may precipitate further cerebral ischemia. Preliminary studies suggest, in fact, that there may be a role in the future for blood pressure elevation in the treatment of patients with acute ischemic stroke. CONCLUSIONS Current data support the use of blood pressure reduction in the secondary prevention of stroke in patients with cerebrovascular disease. In the setting of acute stroke, however, data are limited and blood pressure management must be tailored to the specific clinical situation.
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Affiliation(s)
- Robert J Wityk
- From the Department of Neurology, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, Baltimore, Maryland 21287, USA.
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50
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Marcheselli S, Cavallini A, Tosi P, Quaglini S, Micieli G. Impaired blood pressure increase in acute cardioembolic stroke. J Hypertens 2007; 24:1849-56. [PMID: 16915035 DOI: 10.1097/01.hjh.0000242410.42912.2d] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND PURPOSE Studies on the prognostic significance of blood pressure (BP) increases during the acute phase of ischemic stroke give contradictory results. The aim of this study was to evaluate BP response during the acute phase in different ischemic stroke subtypes, and to assess the prognostic value, considering long-term outcome, of different BP patterns recorded. METHODS We included 110 ischemic stroke patients hospitalized within 6 h of the onset of symptoms. All the patients underwent 24-h monitoring on hospital admission and on day 7 after stroke. For statistical analysis the whole population was divided into cardioembolic (CE), atherothrombotic (AT) and lacunar (LAC) groups, according to TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria. RESULTS In both the whole population and in all subgroups systolic and diastolic BP were higher at admission than during monitoring on day 7, the lowest values being recorded in the CE subgroup. CE stroke was significantly related to lower BP (systolic and diastolic) values (P = 0.01) during the acute phase and CE patients were characterized by poorer outcome. A history of diabetes was a predictor of higher systolic and diastolic BP on the first day of monitoring; higher systolic and diastolic BP values were related to a history of hypertension and with male gender, respectively. Predictors of death by 6-months were atrial fibrillation, age and history of hypertension (P < 0.05) while higher systolic BP in the acute phase seems to represent a protective factor. CONCLUSION CE stroke shows a lack of BP response during the acute phase of ischemic stroke. This phenomenon is associated with a poor long-term outcome and seems not be related with cardiac co-morbidity.
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