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Karagiannaki A, Kakaletsis N, Chouvarda I, Dourliou V, Milionis H, Savopoulos C, Ntaios G. Association between antihypertensive treatment, blood pressure variability, and stroke severity and outcomes in acute ischemic stroke. J Clin Neurosci 2024; 125:51-58. [PMID: 38754240 DOI: 10.1016/j.jocn.2024.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/25/2024] [Accepted: 05/10/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVES The management of blood pressure (BP) and the role of antihypertensive medications (AHT) in acute ischemic stroke (AIS) remain uncertain. This study aimed to investigate the impact of pre- and intra-stroke AHT use on systolic (SBP), diastolic (DBP), and blood pressure variability (BPV). MATERIALS AND METHODS A post-hoc analysis was conducted on 228 AIS patients from the PREVISE study. All patients underwent 24-hour ambulatory blood pressure monitoring within 48 h of symptom onset. Clinical and laboratory data, as well as AHT details, were recorded. Mean BP parameters and BPV for SBP and DBP were computed. The study endpoint was 3-month mortality. RESULTS The majority of stroke patients (84.2%) were already taking AHTs. Beta blockers and ACE inhibitors use before and after stroke were linked to higher DBP variability. Prior angiotensin receptor blockers (ARBs) and vasodilators use correlated with increased SBP variability and lower daytime SBP/DBP levels, respectively. The continuation, discontinuation, or change of AHTs after stroke onset did not significantly affect outcomes. Patients under AHTs during AIS exhibited reduced mortality, with those previously using calcium channel blockers experiencing less severe strokes, and those previously using ARBs showing better outcomes at three months. CONCLUSIONS These findings advocate for personalized BP management in AIS, based on a patient's antihypertensive history. These insights could enhance treatment efficacy, guide research, and improve care for acute ischemic stroke patients.
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Affiliation(s)
- Anastasia Karagiannaki
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.
| | - Nikolaos Kakaletsis
- First Propedeutic Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Greece
| | - Ioanna Chouvarda
- Laboratory of Computing, Medical Informatics and Biomedical - Imaging Technologies, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasiliki Dourliou
- First Propedeutic Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Greece
| | - Haralampos Milionis
- Department of Internal Medicine, University Hospital of Ioannina, University of Ioannina, Greece
| | - Christos Savopoulos
- First Propedeutic Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Greece
| | - George Ntaios
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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2
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Fan K, Cao W, Chang H, Tian F. Predicting prognosis in patients with stroke treated with intravenous alteplase through blood pressure changes: A machine learning-based approach. J Clin Hypertens (Greenwich) 2023; 25:1009-1018. [PMID: 37843065 PMCID: PMC10631101 DOI: 10.1111/jch.14732] [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: 05/09/2023] [Revised: 08/21/2023] [Accepted: 09/15/2023] [Indexed: 10/17/2023]
Abstract
The use of machine learning (ML) in predicting disease prognosis has increased, and researchers have adopted different methods for variable selection to optimize early screening for AIS to determine its prognosis as soon as possible. We aimed to improve the understanding of the predictors of poor functional outcome at three months after discharge in AIS patients treated with intravenous thrombolysis and to construct a highly effective prognostic model to improve prediction accuracy. And four ML methods (random forest, support vector machine, naive Bayesian, and logistic regression) were used to screen and recombine the features for construction of an ML prognostic model. A total of 352 patients that had experienced AIS and had been treated with intravenous thrombolysis were recruited. The variables included in the model were NIHSS on admission, age, white blood cell count, percentage of neutrophils and triglyceride after thrombolysis, tirofiban, early neurological deterioration, early neurological improvement, and BP at each time point or period. The model's area under the curve for predicting 30-day modified Rankin scale was 0.790 with random forest, 0.542 with support vector machine, 0.411 with naive Bayesian, and 0.661 with logistic regression. The random forest model was shown to accurately evaluate the prognosis of AIS patients treated with intravenous thrombolysis, and therefore they may be helpful for accurate and personalized secondary prevention. The model offers improved prediction accuracy that may reduce rates of misdiagnosis and missed diagnosis in patients with AIS.
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Affiliation(s)
- Kaiting Fan
- Department of NeurologyXuanwu Hospital, Capital Medical University, National Clinical Research Center for Geriatric DiseaseBeijingChina
| | - Wenya Cao
- Department of NeurologyXuanwu Hospital, Capital Medical University, National Clinical Research Center for Geriatric DiseaseBeijingChina
| | - Hong Chang
- Department of NeurologyXuanwu Hospital, Capital Medical University, National Clinical Research Center for Geriatric DiseaseBeijingChina
| | - Fei Tian
- Department of NeurologyXuanwu Hospital, Capital Medical University, National Clinical Research Center for Geriatric DiseaseBeijingChina
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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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4
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Wallen M, Banerjee P, Webb-McAdams A, Mirajkar A, Stead T, Ganti L. Systolic blood pressure in acute ischemic stroke and impact on clinical outcomes. J Osteopath Med 2023:jom-2022-0191. [PMID: 37043363 DOI: 10.1515/jom-2022-0191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 03/13/2023] [Indexed: 04/13/2023]
Abstract
CONTEXT Stroke is one of the largest healthcare burdens in the United States and globally. It continues to be one of the leading causes of morbidity and mortality. Patients with acute ischemic stroke (AIS) often present with elevated blood pressure (BP). OBJECTIVES The objective of our study was to evaluate the association of systolic blood pressure (SBP) in the emergency department (ED) with stroke severity in patients with AIS. METHODS This observational study was conducted at an ED with an annual census of 80,000 visits, approximately half (400) of which are for AIS. The cohort consisted of adult patients who presented to the ED within 24 h of stroke symptom onset. BP was measured at triage by a nurse blinded to the study. Stroke severity was measured utilizing the National Institutes of Health Stroke Scale (NIHSS). Statistical analyses were performed utilizing JMP 14.0. This study was approved by our medical school's institutional review board. RESULTS Patients with higher SBP had significantly lower NIHSS scores (p=0.0038). This association was significant even after adjusting for age and gender. By contrast, diastolic blood pressure (DBP) did not appear to impact stroke severity. There was no difference in the DBP values between men and women. Higher SBP was also significantly associated with being discharged home as well as being less likely to die in the hospital or discharged to hospice. The DBP did not demonstrate this association. Neither the SDP nor the DBP were significantly associated with the hospital length of stay (LOS). In multivariate models that included age, gender, basal metabolic index (BMI), comorbidities, and ED presentation, elevated SBP was associated with better prognosis. CONCLUSIONS In this cohort of patients presenting with stroke-like symptoms to the ED, higher SBP was associated with lower stroke severity and higher rates of being discharged to home rather than hospice or death.
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Affiliation(s)
| | - Paul Banerjee
- Envision Physician Services, Plantation, FL, USA
- Polk County Fire Rescue, Bartow, FL, USA
| | - Amanda Webb-McAdams
- Envision Physician Services, Plantation, FL, USA
- University of Central Florida College of Medicine/HCA GME Consortium, Orlando, FL, USA
| | - Amber Mirajkar
- Envision Physician Services, Plantation, FL, USA
- University of Central Florida College of Medicine/HCA GME Consortium, Orlando, FL, USA
| | - Tej Stead
- Brown University, Providence, RI, USA
| | - Latha Ganti
- Envision Physician Services, Plantation, FL, USA
- University of Central Florida College of Medicine/HCA GME Consortium, Orlando, FL, USA
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De Georgia M, Bowen T, Duncan KR, Chebl AB. Blood pressure management in ischemic stroke patients undergoing mechanical thrombectomy. Neurol Res Pract 2023; 5:12. [PMID: 36991520 PMCID: PMC10061853 DOI: 10.1186/s42466-023-00238-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 03/14/2023] [Indexed: 03/31/2023] Open
Abstract
The relationship between presenting blood pressure in acute ischemic stroke patients and outcome is complex. Several studies have demonstrated a U-shaped curve with worse outcomes when blood pressure is high or low. The American Heart Association/American Stroke Association guidelines recommend values of blood pressure < 185/110 mmHg in patients treated with intravenous t-PA and "permissive hypertension" up to 220/120 mmHg in those not treated with intravenous t-PA. The optimal blood pressure target is less clear in patients undergoing mechanical thrombectomy. Before thrombectomy, the guidelines recommend a blood pressure < 185/110 mmHg though patients with even lower systolic blood pressures may have better outcomes. During and after thrombectomy, the guidelines recommend a blood pressure < 180/105 mmHg. However, several studies have suggested that during thrombectomy the primary goal should be to prevent significant low blood pressure (e.g., target systolic blood pressure > 140 mmHg or MAP > 70 mmHg). After thrombectomy, the primary goal should be to prevent high blood pressure (e.g., target systolic blood pressure < 160 mmHg or MAP < 90 mmHg). To make more specific recommendations, large, randomized-control studies are needed that address factors such as the baseline blood pressure, timing and degree of revascularization, status of collaterals, and estimated risk of reperfusion injury.
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Affiliation(s)
- Michael De Georgia
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - Theodore Bowen
- Department of Neurology, MetroHealth Medical Center, Cleveland, OH, USA
| | - K Rose Duncan
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Alex Bou Chebl
- Department of Neurology, Henry Ford Medical Center, Detroit, MI, USA
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6
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Ahn S, Howie-Esquivel J, Davis EM, Chung ML, Lobo JM, Logan JG. Association of disrupted sleep with 24-hour blood pressure variability in caregivers. Heart Lung 2023; 60:45-51. [PMID: 36905754 DOI: 10.1016/j.hrtlng.2023.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/21/2023] [Accepted: 02/26/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND A growing body of research highlights the negative impact of caregiving on cardiovascular disease (CVD) risk. OBJECTIVES This study aimed to examine associations of psychological symptoms and sleep quality with 24-hour blood pressure variability (BPV), which is an independent predictor of CVD, among family caregivers of community-dwelling individuals with chronic illness. METHODS For this cross-sectional study, we assessed caregiving burden and depressive symptoms using questionnaires and 7-day sleep quality (i.e., number of awakenings, wake after sleep onset, sleep efficiency) using an actigraph. The participants carried out a 24-hour ambulatory BP monitoring for systolic and diastolic BPV over 24 h and during awake/sleep times. We performed Pearson's correlations and multiple linear regression. RESULTS The analytic sample consisted of 30 caregivers (25 female; mean age 62 years). The number of awakenings during sleep was positively correlated with systolic BPV-awake (r = 0.426, p = 0.019) and diastolic BPV-awake (r = 0.422, p = 0.020). Sleep efficiency was negatively correlated with diastolic BPV-awake (r = -0.368, p = 0.045). Caregiving burden and depressive symptoms were not correlated with BPV. After controlling for age and mean arterial pressure, the number of awakenings was significantly associated with increased systolic BPV-24 h (β = 0.194, p = 0.018) and systolic BPV-awake (β = 0.280, p = 0.002), respectively. CONCLUSIONS Caregivers' disrupted sleep may play a role in increased CVD risk. While these findings should be confirmed in large clinical studies, improving sleep quality would need to be considered in CVD prevention for caregivers.
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Affiliation(s)
- Soojung Ahn
- School of Nursing, Vanderbilt University, Nashville, TN, USA.
| | | | - Eric M Davis
- Division of Pulmonary and Critical Care, Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Misook L Chung
- College of Nursing, University of Kentucky, Lexington, KY, USA
| | - Jennifer M Lobo
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Jeongok G Logan
- School of Nursing, University of Virginia, Charlottesville, VA, USA
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Xu C, Jin T, Chen Z, Zhang Z, Zhang K, Mao H, Ye S, Geng Y, Shi Z. Increased blood pressure variability during general anaesthesia is associated with worse outcomes after mechanical thrombectomy: a prospective observational cohort study. BMJ Open 2022; 12:e059108. [PMID: 36198453 PMCID: PMC9535158 DOI: 10.1136/bmjopen-2021-059108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES Optimal periprocedural blood pressure (BP) management during mechanical thrombectomy (MT) for acute ischaemic stroke is still controversial. The aim of this study was to investigate the association between intraprocedural BP variability (BPV) and outcomes in patients with large vessel occlusion (LVO) following MT with general anaesthesia. DESIGN A prospective observational cohort study. SETTING This study was conducted in a single tertiary hospital of Hangzhou in Zhejiang province. PARTICIPANTS A total of 141 patients with LVO treated with MT were finally included between January 2018 and September 2020. MAIN OUTCOME MEASURES Intraprocedural BP was recorded every 5 min throughout the procedure. BPV was measured as SD, coefficient of variation (CV), max-min (RANGE) and successive variation. Haemorrhagic transformation was assessed on 24-hour CT images according to European Cooperative Acute Stroke Study III trial. Poor functional outcome was defined as 90-day modified Rankin Scale score 3-6. Binary logistic regression analysis was used to investigate the association of BPV parameters with the incidence of parenchymal haemorrhage (PH) and poor functional outcome. RESULTS After controlling for age, female, history of smoking, hypertension and atrial fibrillation, baseline National Institutes of Health Stroke Scale, baseline systolic BP (SBP), baseline Alberta Stroke Program Early CT Score, bridging thrombolysis and times of retrieval attempts, the results demonstrated that intraprocedural SBPRANGE (OR 1.029; 95% CI 1.003 to 1.055; p=0.027), SBPSD (OR 1.135; 95% CI 1.023 to 1.259; p=0.017) and SBPCV (OR 1.189; 95% CI 1.053 to 1.342; p=0.005) were independently associated with poor functional outcome. However, the independent association between intraprocedural BPV and PH at 24 hours has not been established in this study. CONCLUSIONS Increased intraprocedural BPV was more likely to have poor functional outcome in patients with LVO following MT with general anaesthesia. This finding indicates that special precautions should be taken to minimise BP fluctuation during procedure.
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Affiliation(s)
- Chao Xu
- Department of Neurology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Tianyu Jin
- Department of Neurology, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Zhicai Chen
- Department of Neurology, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, Zhejiang, China
| | - Zheyu Zhang
- Department of Neurology, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Kemeng Zhang
- Department of Neurology, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, Zhejiang, China
| | - Hui Mao
- Department of Anesthesiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Sasa Ye
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Yu Geng
- Department of Neurology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Zongjie Shi
- Department of Neurology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
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Xu X, Peng S, Zhou Y, Li J, Tong L, Gao F. Remote diffusion-weighted imaging lesions and blood pressure variability in primary intracerebral hemorrhage. Front Neurol 2022; 13:950056. [PMID: 36203972 PMCID: PMC9530136 DOI: 10.3389/fneur.2022.950056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 08/12/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThe aim of this study was to examine the association between remote diffusion-weighted imaging lesions (R-DWILs) and blood pressure variability (BPV) in patients with primary intracerebral hemorrhage (ICH).MethodsWe conducted a retrospective review of a consecutive cohort of 375 patients with primary ICH within 24 h onset. R-DWILs were defined as hyperintensity lesions in DWI remote from the hematoma. Blood pressure recordings were extracted up to 24 h post-admission. BPV was measured using SD, coefficient of variation (CV), and successive variation (SV).ResultsRemote DWI lesions were detected in 65 (17.3%) primary ICH patients. In multivariable logistic regression analysis, parameters of BPV were independently associated with R-DWILs, and the results remained consistent after being adjusted with mean SBP. SD, CV, and SV values in the highest quintile, showed 3- to 8-fold increased risk of R-DWILs, compared with the lowest quintile. ΔSBP demonstrated a significant difference in 2 different predictive models. Max SBP only dictated a significant difference in model 1. Mean SBP, admission SBP, and min SBP, failed to present an association with R-DWILs in model 1 or model 2.ConclusionOur results provided additional evidence that BPV is associated with the development of R-DWILs in primary ICH.
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Affiliation(s)
- Xuhua Xu
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Neurology, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, China
| | - Shuangshuang Peng
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Neurology, Taizhou First People's Hospital, Taizhou, China
| | - Yanli Zhou
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Neurology, Taizhou First People's Hospital, Taizhou, China
| | - Jiawen Li
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lusha Tong
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Lusha Tong
| | - Feng Gao
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- *Correspondence: Feng Gao
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Liu P, Hao J, Zhang Y, Wang L, Liu C, Wang J, Feng J, Zhang Y, Hou H, Zhang L. Acute Ischemic Stroke Comorbid with Type 2 Diabetes: Long-Term Prognosis Determinants in a 36-Month Prospective Study for Personalized Medicine. OMICS : A JOURNAL OF INTEGRATIVE BIOLOGY 2022; 26:451-460. [PMID: 35917518 DOI: 10.1089/omi.2022.0071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Ischemic stroke (IS) is often comorbid with type 2 diabetes mellitus (T2DM) wherein the determinants of long-term outcomes, beyond the acute stroke phase, are not adequately known. This study identified the determinants of long-term outcomes for diabetic IS patients through a prospective nested case-control study in 624 patients treated with conservative measures (38.60% females, mean age: 63.85 years). After 36-month follow-up, 117 (18.8%) patients with poor outcome were enrolled in the case group. The poor outcome was defined with a modified Rankin Scale (mRS) score ≥3. Meanwhile, 374 (59.9%) patients with good outcome, defined as (mRS score <3), were included in the control group. Patients who died (n = 32) or lost to follow-up (n = 101) were excluded in analysis. Poor prognostic outcome was positively associated with (1) the pulse rate at admission, (2) diastolic blood pressure (DBP), and (3) fasting blood glucose (FBG) during follow-up, whereas physical activity and lipid-lowering treatment during follow-up were negatively associated. Importantly, a forecasting model with these indicators distinguished the patients with good versus poor outcomes with 70.1% sensitivity and 73.5% specificity. Health care professionals and laboratory medicine scholars may want to monitor an increase in DBP and FBG during follow-up, as well as physical activity and lipid-lowering treatment, in relationship to the prognosis of IS with comorbid T2DM after conservative therapies. The proposed predictive model for personalized/precision medicine requires field testing in independent studies, and might help risk stratification with theranostic tests for patients with acute IS who also have a diagnosis of T2DM.
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Affiliation(s)
- Pengcheng Liu
- Department of Epidemiology, School of Public Health, Shandong First Medical University & Shandong Academy of Medical Sciences, Taian, China
| | - Jiheng Hao
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, China
| | - Yichun Zhang
- Department of Epidemiology, School of Public Health, Shandong First Medical University & Shandong Academy of Medical Sciences, Taian, China
| | - Lu Wang
- Department of Epidemiology, School of Public Health, Shandong First Medical University & Shandong Academy of Medical Sciences, Taian, China
| | - Chao Liu
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, China
| | - Jiyue Wang
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, China
| | - Jingjun Feng
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, China
| | - Yanbo Zhang
- Department of Neurology, The Second Affiliated Hospital of Shandong First Medical University, Taian, China
| | - Haifeng Hou
- Department of Epidemiology, School of Public Health, Shandong First Medical University & Shandong Academy of Medical Sciences, Taian, China
| | - Liyong Zhang
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, China
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10
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Fan JL, Brassard P, Rickards CA, Nogueira RC, Nasr N, McBryde FD, Fisher JP, Tzeng YC. Integrative cerebral blood flow regulation in ischemic stroke. J Cereb Blood Flow Metab 2022; 42:387-403. [PMID: 34259070 PMCID: PMC8985438 DOI: 10.1177/0271678x211032029] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Optimizing cerebral perfusion is key to rescuing salvageable ischemic brain tissue. Despite being an important determinant of cerebral perfusion, there are no effective guidelines for blood pressure (BP) management in acute stroke. The control of cerebral blood flow (CBF) involves a myriad of complex pathways which are largely unaccounted for in stroke management. Due to its unique anatomy and physiology, the cerebrovascular circulation is often treated as a stand-alone system rather than an integral component of the cardiovascular system. In order to optimize the strategies for BP management in acute ischemic stroke, a critical reappraisal of the mechanisms involved in CBF control is needed. In this review, we highlight the important role of collateral circulation and re-examine the pathophysiology of CBF control, namely the determinants of cerebral perfusion pressure gradient and resistance, in the context of stroke. Finally, we summarize the state of our knowledge regarding cardiovascular and cerebrovascular interaction and explore some potential avenues for future research in ischemic stroke.
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Affiliation(s)
- Jui-Lin Fan
- Manaaki Mānawa - The Centre for Heart Research, Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Patrice Brassard
- Department of Kinesiology, Faculty of Medicine, Université Laval, Québec City, Canada.,Research Center of the Institut universitaire de cardiologie et de pneumologie de Québec, Québec City, Canada
| | - Caroline A Rickards
- Department of Physiology & Anatomy, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Ricardo C Nogueira
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, São Paulo, Brazil.,Neurology Department, Hospital Nove de Julho, São Paulo, Brazil
| | - Nathalie Nasr
- Department of Neurology, Toulouse University Hospital, NSERM UMR 1297, Toulouse, France
| | - Fiona D McBryde
- Manaaki Mānawa - The Centre for Heart Research, Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - James P Fisher
- Manaaki Mānawa - The Centre for Heart Research, Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Yu-Chieh Tzeng
- Wellington Medical Technology Group, Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand.,Department of Surgery & Anaesthesia, Centre for Translational Physiology, University of Otago, Wellington, New Zealand
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11
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Fan JL, Nogueira RC, Brassard P, Rickards CA, Page M, Nasr N, Tzeng YC. Integrative physiological assessment of cerebral hemodynamics and metabolism in acute ischemic stroke. J Cereb Blood Flow Metab 2022; 42:454-470. [PMID: 34304623 PMCID: PMC8985442 DOI: 10.1177/0271678x211033732] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Restoring perfusion to ischemic tissue is the primary goal of acute ischemic stroke care, yet only a small portion of patients receive reperfusion treatment. Since blood pressure (BP) is an important determinant of cerebral perfusion, effective BP management could facilitate reperfusion. But how BP should be managed in very early phase of ischemic stroke remains a contentious issue, due to the lack of clear evidence. Given the complex relationship between BP and cerebral blood flow (CBF)-termed cerebral autoregulation (CA)-bedside monitoring of cerebral perfusion and oxygenation could help guide BP management, thereby improve stroke patient outcome. The aim of INFOMATAS is to 'identify novel therapeutic targets for treatment and management in acute ischemic stroke'. In this review, we identify novel physiological parameters which could be used to guide BP management in acute stroke, and explore methodologies for monitoring them at the bedside. We outline the challenges in translating these potential prognostic markers into clinical use.
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Affiliation(s)
- Jui-Lin Fan
- Manaaki Mānawa - The Centre for Heart Research, Department of Physiology, Faculty of Medical & Health Sciences, University of Auckland, Auckland, New Zealand
| | - Ricardo C Nogueira
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, São Paulo, Brazil.,Neurology Department, Hospital Nove de Julho, São Paulo, Brazil
| | - Patrice Brassard
- Department of Kinesiology, Faculty of Medicine, Université Laval, Québec, Canada.,Research Center of the Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada
| | - Caroline A Rickards
- Department of Physiology & Anatomy, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Matthew Page
- Department of Radiology, Wellington Regional Hospital, Wellington, New Zealand
| | - Nathalie Nasr
- Department of Neurology, Toulouse University Hospital, NSERM UMR 1297, Toulouse, France
| | - Yu-Chieh Tzeng
- Wellington Medical Technology Group, Department of Surgery & Anaesthesia, University of Otago, Wellington, New Zealand.,Centre for Translational Physiology, Department of Surgery & Anaesthesia, University of Otago, Wellington, New Zealand
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12
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Barow E, Boutitie F, Cheng B, Cho TH, Ebinger M, Endres M, Fiebach JB, Fiehler J, Nickel A, Puig J, Roy P, Lemmens R, Thijs V, Muir KW, Nighoghossian N, Pedraza S, Simonsen CZ, Gerloff C, Thomalla G. 24-hour blood pressure variability and treatment effect of intravenous alteplase in acute ischaemic stroke. Eur Stroke J 2021; 6:168-175. [PMID: 34414292 DOI: 10.1177/23969873211014758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 04/14/2021] [Indexed: 01/01/2023] Open
Abstract
Introduction To assess the association between 24 h blood pressure variability (BPV) on functional outcome and treatment effect of intravenous alteplase in acute ischaemic stroke. Patients and methods In all patients with acute ischaemic stroke of unknown onset randomised in the WAKE-UP (Efficacy and Safety of magnetic resonance imaging [MRI]-based Thrombolysis in Wake-Up Stroke) trial, blood pressure (BP) was measured before randomisation and after initiation of treatment at regular intervals up to 24 hours. Individual BPV was measured by coefficient of variation (CV) of all BP values. Primary outcome measure was favourable outcome defined by a modified Rankin Scale (mRS) score 0 or 1 at 90 days after stroke. Results BP measurements were available for 498 of 503 patients randomised (177 women [35.5%], mean age [SD] of 65.2 [11.5] years). Systolic BPV was not associated with the treatment effect of thrombolysis (test for interaction, p = 0.46). The adjusted odds ratio (aOR) for favourable outcome with alteplase, adjusted for age, stroke severity and baseline BP on admission, did not show an association across the quintiles of increasing systolic BPV with an aOR 1.89 (95% confidence interval [CI], 0.76-4.70) in the lowest quintile to aOR 1.05 (95% CI, 0.43-2.56) in the highest quintile. Higher mean systolic BP was associated with a smaller treatment effect of thrombolysis with a significant interaction (p = 0.033). The aOR for favourable outcome with alteplase decreased with quintiles of increasing mean systolic BP from aOR 3.16 (95% CI, 1.26-7.93) in the lowest quintile to aOR 0.84 (95% CI, 0.34-2.10) in in the highest quintile. Conclusions There was a significant interaction between mean systolic BP and treatment effect of thrombolysis with higher mean systolic BP being associated with poorer outcome. BPV was not associated with outcome after thrombolysis.ClinicalTrials.gov identifier NCT01525290.
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Affiliation(s)
- Ewgenia Barow
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Florent Boutitie
- Hospices Civils de Lyon, Service de Biostatistique, Lyon, France
| | - Bastian Cheng
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Martin Ebinger
- Centrum für Schlaganfallforschung Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany.,Medical Park Berlin Humboldtmühle, Klinik für Neurologie, Berlin, Germany
| | - Matthias Endres
- Centrum für Schlaganfallforschung Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jochen B Fiebach
- Centrum für Schlaganfallforschung Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alina Nickel
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Josep Puig
- Department of Radiology, Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut d'Investigació Biomèdica de Girona (IDIBGI), Parc Hospitalari Martí i Julià de Salt - Edifici M2, Girona, Spain
| | - Pascal Roy
- Hospices Civils de Lyon, Service de Biostatistique, Lyon, France
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium.,KU Leuven - University of Leuven, Department of Neurosciences, Experimental Neurology, Leuven, Belgium.,VIB, Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium
| | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Victoria, Australia.,Austin Health, Department of Neurology, Heidelberg, Australia
| | - Keith W Muir
- Institute of Neuroscience & Psychology, University of Glasgow, University Avenue, Glasgow, UK
| | | | - Salvador Pedraza
- Department of Radiology, Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut d'Investigació Biomèdica de Girona (IDIBGI), Parc Hospitalari Martí i Julià de Salt - Edifici M2, Girona, Spain
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Christian Gerloff
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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13
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Chapman CL, Reed EL, Worley ML, Pietrafesa LD, Kueck PJ, Bloomfield AC, Schlader ZJ, Johnson BD. Sugar-sweetened soft drink consumption acutely decreases spontaneous baroreflex sensitivity and heart rate variability. Am J Physiol Regul Integr Comp Physiol 2021; 320:R641-R652. [PMID: 33533320 DOI: 10.1152/ajpregu.00310.2020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
In healthy humans, fructose-sweetened water consumption increases blood pressure variability (BPV) and decreases spontaneous cardiovagal baroreflex sensitivity (cBRS) and heart rate variability (HRV). However, whether consuming commercially available soft drinks containing high levels of fructose elicits similar responses is unknown. We hypothesized that high-fructose corn syrup (HFCS)-sweetened soft drink consumption increases BPV and decreases cBRS and HRV to a greater extent compared with artificially sweetened (diet) and sucrose-sweetened (sucrose) soft drinks and water. Twelve subjects completed four randomized, double-blinded trials in which they drank 500 mL of water or commercially available soft drinks matched for taste and caffeine content. We continuously measured beat-to-beat blood pressure (photoplethysmography) and R-R interval (ECG) before and 30 min after drink consumption during supine rest for 5 min during spontaneous and paced breathing. BPV was evaluated using standard deviation (SD), average real variability (ARV), and successive variation (SV) methods for systolic and diastolic blood pressure. cBRS was assessed using the sequence method. HRV was evaluated using the root mean square of successive differences (RMSSD) in R-R interval. There were no differences between conditions in the magnitude of change from baseline in SD, ARV, and SV (P ≥ 0.07). There were greater reductions in cBRS during spontaneous breathing in the HFCS (-3 ± 5 ms/mmHg) and sucrose (-3 ± 5 ms/mmHg) trials compared with the water trial (+1 ± 5 ms/mmHg, P < 0.03). During paced breathing, HFCS evoked greater reductions in RMSSD compared with water (-26 ± 34 vs. +2 ± 26 ms, P < 0.01). These findings suggest that sugar-sweetened soft drink consumption alters cBRS and HRV but not BPV.
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Affiliation(s)
- Christopher L Chapman
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, New York.,Department of Human Physiology, University of Oregon, Eugene, Oregon
| | - Emma L Reed
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, New York.,Department of Human Physiology, University of Oregon, Eugene, Oregon
| | - Morgan L Worley
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, New York.,Department of Kinesiology, School of Public Health, Indiana University, Bloomington, Indiana
| | - Leonard D Pietrafesa
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, New York
| | - Paul J Kueck
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, New York
| | - Adam C Bloomfield
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, New York
| | - Zachary J Schlader
- Department of Kinesiology, School of Public Health, Indiana University, Bloomington, Indiana
| | - Blair D Johnson
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, New York.,Department of Kinesiology, School of Public Health, Indiana University, Bloomington, Indiana
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14
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Optimal blood pressure levels in different phases of peripheral thrombolysis period in acute ischemic stroke. J Hypertens 2021; 39:1453-1461. [PMID: 33560058 DOI: 10.1097/hjh.0000000000002812] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Dramatic changes of blood pressure (BP) were observed in the peripheral thrombolysis period, however, there is no consensus about BP control targets in the different phases. METHODS We retrospectively studied a consecutive sample of 510 patients treated with intravenous thrombolysis and followed-up for 3 months. The peripheral thrombolysis period was divided into these phases: Phase 1 (from onset to thrombolysis), Phase 2 (thrombolysis), Phase 3 (from thrombolysis to 24 h after thrombolysis), and Phase 4 (from 24 h to 7 days after thrombolysis). Patients were divided into quintiles according to mean blood pressure in these phases, respectively. Neurological improvement was evaluated using the modified Rankin Scale score at 3-month after thrombolysis. RESULTS Lower risk of intracerebral hemorrhage within 7 days was found in lower quintiles of SBP (OR = 0.100, 95% CI 0.011-0.887, P = 0.039 in Phase 1 quintile Q1, OR = 0.110, 95% CI 0.012-0.974, P = 0.047 in Phase 2-3 quintile Q1, and OR, 0.175, 95% CI, 0.035-0.872; P = 0.033 in Phase 4 quintile Q2, respectively). Better neurological improvement was found in SBP quintiles: Q2-Q4 (127.3-155.7 mmHg) in Phase 4 (OR = 3.095, 95% CI 1.524-6.286, P = 0.002 for Q2; OR = 2.697, 95% CI 1.354-5.370, P = 0.005 for Q3; and OR = 2.491, 95% CI 1.263-4.913, P = 0.008 for Q4, respectively). Our results also showed higher average real variability of SBP was negatively associated with better neurological outcome in Phase 1 and Phase 2-3. CONCLUSIONS Maintaining SBP levels (≤148 mmHg) from admission to the first 24 h after thrombolysis, then keeping SBP levels (127-138 mmHg) would be beneficial.
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15
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Zhao J, Yuan F, Fu F, Liu Y, Xue C, Wang K, Yuan X, Li D, Liu Q, Zhang W, Jia Y, He J, Zhou J, Wang X, Lv H, Huo K, Li Z, Zhang B, Wang C, Li L, Li H, Yang F, Jiang W. Blood pressure variability and outcome in acute severe stroke: A post hoc analysis of CHASE-A randomized controlled trial. J Clin Hypertens (Greenwich) 2020; 23:96-102. [PMID: 33226186 PMCID: PMC8029725 DOI: 10.1111/jch.14090] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 09/28/2020] [Accepted: 09/30/2020] [Indexed: 11/29/2022]
Abstract
The influence of blood pressure variability (BPV) on outcomes in patients with severe stroke is still largely unsettled. Using the data of CHASE trial, the authors calculated the BPV during the acute phase and subacute phase of severe stroke, respectively. The primary outcome was to investigate the relationship between BPV and 90‐day modified Rankin scale (mRS) ≥ 3. The BPV was assessed by eight measurements including standard deviation (SD), mean, maximum, minimum, coefficient of variation (CV), successive variation (SV), functional successive variation (FSV), and average real variability (ARV). Then, the SD of SBP was divided into quintiles and compared the quintile using logistic regression in three models. The acute phase included 442 patients, and the subacute phase included 390 patients. After adjustment, six measurements of BPV during the subacute phase rather than acute phase were strongly correlated with outcomes including minimum (odds ratio [OR]: 0.83, 95% confidence interval [CI]: 0.69‐0.99, p = .037), SD (OR: 1.10, 95% CI: 1.03‐1.17, p = .007), CV (OR: 1.12, 95% CI: 1.03‐1.23, p = .012), ARV (OR: 1.13, 95% CI: 1.05‐1.20, p < .001), SV (OR: 1.09, 95% CI: 1.04‐1.15, p = .001), and FSV (OR: 1.12, 95% CI: 1.05‐1.19, p = .001). In the logistic regression, the highest fifth of SD of SBP predicted poor outcome in all three models. In conclusion, the increased BPV was strongly correlated with poor outcomes in the subacute phase of severe stroke, and the magnitude of association was progressively increased when the SD of BP was above 12.
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Affiliation(s)
- Jingjing Zhao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Fang Yuan
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Feng Fu
- Department of Neurology, 215 Hospital of Shaanxi NI, Xianyang, China
| | - Yi Liu
- Department of Neurology, Ankang Central Hospital, Ankang, China
| | - Changhu Xue
- Department of Neurology, Xianyang Central Hospital, Xianyang, China
| | - Kangjun Wang
- Department of Neurology, Hanzhong Central Hospital, Hanzhong, China
| | - Xiangjun Yuan
- Department of Neurology, Weinan Central Hospital, Weinan, China
| | - Dingan Li
- Department of Neurology, Hanzhong Central Hospital, Hanzhong, China
| | - Qiuwu Liu
- Department of Neurology, Xi'an 141 Hospital, Xi'an, China
| | - Wei Zhang
- Department of Neurology, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Yi Jia
- Department of Neurology, Xi'an Gaoxin Hospital, Xi'an, China
| | - Jianbo He
- Department of Neurology, Xi'an XD Group Hospital, Xi'an, China
| | - Jun Zhou
- Department of Neurology, Shangluo Central Hospital, Shangluo, China
| | - Xiaocheng Wang
- Department of Neurology, Yulin No. 2 Central Hospital, Yulin, China
| | - Hua Lv
- Department of Neurology, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Kang Huo
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Zhuanhui Li
- Department of Neurology, 521 Hospital of NORINCO Group, Xi'an, China
| | - Bei Zhang
- Department of Neurology, The First Affiliated Hospital of Xi'an Medical University, Xi'an, China
| | - Chengkai Wang
- Department of Neurology, Tongchuan People's Hospital, Tongchuan, China
| | - Li Li
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.,The Shaanxi Cerebrovascular Disease Clinical Research Center, Xi'an, China
| | - Hongzeng Li
- Department of Neurology, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Fang Yang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.,The Shaanxi Cerebrovascular Disease Clinical Research Center, Xi'an, China
| | - Wen Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.,The Shaanxi Cerebrovascular Disease Clinical Research Center, Xi'an, China
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16
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Yang C, Liu K, Song Y, Gong S, Ye R, Zhang Z, Chen X. Day-by-Day Blood Pressure Variability Is Associated With Neurological Functional Outcome After Acute Ischemic Stroke. Front Neurol 2020; 11:566825. [PMID: 33281703 PMCID: PMC7691487 DOI: 10.3389/fneur.2020.566825] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 10/05/2020] [Indexed: 02/05/2023] Open
Abstract
Background: Increased blood pressure variability (BPV) might be a detrimental factor after acute ischemic stroke. Previous studies on the association between blood pressure variability in the acute ischemic stroke and functional outcome have yielded inconsistent results. We aimed to investigate the impact of day-by-day blood pressure variability within 7 days of onset on functional outcome at 3 months after acute ischemic stroke. Methods: Total 367 patients hospitalized for ischemic stroke within 48 h of onset were enrolled. The acute stage of ischemic stroke was defined as the time period from symptom onset to 7 days. During this period, blood pressure was measured twice daily (respectively, in the morning during 8:00 a.m.−10:00 a.m., in the afternoon between 15:00 p.m. and 17:00 p.m.). Day-by-day blood pressure variability, including standard deviation (SD) and coefficient variation (CV) were derived and compared to functional outcome. We dichotomized function outcome according to mRS score and unfavorable outcome was defined as mRS ≥3. Results: The patients with unfavorable outcome had significantly higher systolic BPV (within 7 days of onset) than those with favorable outcome (15.41 ± 4.59 vs. 13.42 ± 3.95 mmHg for SD, P < 0.001; 11.54 ± 3.23 vs. 10.41 ± 2.82 for CV, P = 0.001). Multivariable logistic regression analysis revealed that systolic BPV was significantly and independently associated with the 3-month functional outcome [odds ratio (OR) = 1.15, 95% confidence interval (CI): 1.07–1.22, P < 0.001 for SD; OR = 1.15, 95% CI: 1.06–1.26, P = 0.001 for CV]. In addition, After adjustment for multiple confounding factors, including age, gender, risk factors, stroke features, baseline severity, recanalized therapy, hemorrhagic transformation, pulmonary infection, white blood cell, estimated Glomerular Filtration Rate and mean BP, day-by-day BP variability was significantly correlated with an unfavorable outcome in the top vs. bottom quartile of systolic BPV (OR = 3.33, 95% CI: 1.41–7.85, P = 0.006 for SD; OR = 2.27, 95% CI: 1.04–4.94, P = 0.037 for CV) during 3-month follow-up. Similar trends were also observed for diastolic BPV. More importantly, incorporating SD of systolic BP into the conventional prediction model could significantly increase the AUC for prediction of 3-month unfavorable outcome after acute ischemic stroke (0.84 vs. 0.86; P = 0.0416). Conclusions: Increased day-by-day blood pressure variability of systolic or diastolic BP in the acute ischemic stroke was associated with higher risk for unfavorable outcome at 3 months independent of blood pressure levels. Combining SD of systolic BP with conventional risk factors could improve the prediction of unfavorable outcome.
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Affiliation(s)
| | - Kai Liu
- West China Hospital, Sichuan University, Chengdu, China
| | - Yue Song
- West China Second University Hospital, Sichuan University, Chengdu, China
| | - Shenzhen Gong
- West China Hospital, Sichuan University, Chengdu, China
| | - Runyu Ye
- West China Hospital, Sichuan University, Chengdu, China
| | - Zhipeng Zhang
- West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoping Chen
- West China Hospital, Sichuan University, Chengdu, China
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17
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Fan JL, O’Donnell T, Lanford J, Croft K, Watson E, Smyth D, Koch H, Wong LK, Tzeng YC. Dietary nitrate reduces blood pressure and cerebral artery velocity fluctuations and improves cerebral autoregulation in transient ischemic attack patients. J Appl Physiol (1985) 2020; 129:547-557. [DOI: 10.1152/japplphysiol.00160.2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
We found dietary nitrate supplementation reduced blood pressure and brain blood flow fluctuations and improved the relationship between blood pressure and brain blood flow in transient ischemic attack patients. Meanwhile, dietary nitrate had no effects on the brain blood vessels’ response to CO2. We attribute the improved brain blood flow stability to the improved myogenic control of blood pressure with dietary nitrate. Our findings indicate that dietary nitrate could be an effective strategy for stabilizing blood pressure and brain blood flow following transient ischemic attack.
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Affiliation(s)
- Jui-Lin Fan
- Wellington Medical Technology Group, Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
- Centre for Translational Physiology, University of Otago, Wellington, New Zealand
| | - Terrence O’Donnell
- Wellington Medical Technology Group, Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
- Centre for Translational Physiology, University of Otago, Wellington, New Zealand
| | - Jeremy Lanford
- Department of Neurology, Wellington Regional Hospital, Wellington, New Zealand
| | - Kevin Croft
- School of Biomedical Science, University of Western Australia, Perth, Australia
| | - Eloise Watson
- Department of Neurology, Wellington Regional Hospital, Wellington, New Zealand
| | - Duncan Smyth
- Department of Neurology, Wellington Regional Hospital, Wellington, New Zealand
| | - Henrietta Koch
- School of Biomedical Science, University of Western Australia, Perth, Australia
| | - Lai-Kin Wong
- Department of Neurology, Wellington Regional Hospital, Wellington, New Zealand
| | - Yu-Chieh Tzeng
- Wellington Medical Technology Group, Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
- Centre for Translational Physiology, University of Otago, Wellington, New Zealand
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18
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Blood pressure variability and outcome after acute intracerebral hemorrhage. J Neurol Sci 2020; 413:116766. [PMID: 32151850 DOI: 10.1016/j.jns.2020.116766] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 02/24/2020] [Accepted: 03/01/2020] [Indexed: 01/12/2023]
Abstract
Intracerebral hemorrhage (ICH) is life threatening neurologic event that results in significant rate of morbidity and mortality. Unfortunately, several randomized clinical trials aiming at limiting the hematoma expansion (HE) in the acute phase of ICH have not shown significant effects in improving the functional outcomes. Blood pressure variability (BPV) is common following ICH. High BPs have been associated with increased risk of bleeding and HE. Conversely, recurrent sudden decrease in BP promote perihematomal ischemia. However, it is still not clear weather BPV causes adverse prognosis following ICH or large ICHs cause fluctuations in BP. In the current review, we will discuss the mechanistic pathophysiology of BPV and the evidence regarding the role of BPV on the ICH outcomes.
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19
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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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20
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Cho BH, Kim JT, Lee JS, Park MS, Kang KW, Choi KH, Lee SH, Choi SM, Kim BC, Kim MK, Cho KH. Associations of various blood pressure parameters with functional outcomes after endovascular thrombectomy in acute ischaemic stroke. Eur J Neurol 2019; 26:1019-1027. [PMID: 30868681 DOI: 10.1111/ene.13951] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 03/11/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND PURPOSE High blood pressure (BP) at presentation is associated with poor outcomes in acute ischaemic stroke, but serial BP measurements may better delineate the clinical implications of BP. The aim was to investigate the association between various BP parameters and functional outcomes in acute ischaemic stroke patients treated with endovascular thrombectomy (EVT). METHODS This study reports a retrospective analysis of a prospective registry of a comprehensive stroke centre. Patients treated with EVT due to large vessel occlusion in the anterior circulation were enrolled. BP was measured hourly during the first 24 h after admission. Associations of various BP parameters, including BP variability, with functional outcomes at 3 months, including good outcomes (modified Rankin Scale score of 0-2), were analysed. RESULTS Of the 378 enrolled patients (mean age 70 ± 11 years, male 54.2%), 313 (82.8%) achieved successful reperfusion after EVT, and 149 (39.4%) had good outcomes at 3 months. Higher mean systolic BP [each 10 mmHg increase, odds ratio 0.82 (0.69-0.97)] and higher systolic successive variation (SV) [each 10% increase, odds ratio 0.37 (0.18-0.76)] were associated with a reduced likelihood of achieving good outcomes. In addition, reperfusion status after EVT moderated the influence of higher systolic SV on good outcomes (Pint = 0.05). CONCLUSION The results showed that a higher mean systolic BP and systolic SV during the first 24 h of EVT reduced the likelihood of good outcomes at 3 months. The effects of these parameters on outcomes are more substantial amongst patients with successful reperfusion after EVT, suggesting that different BP control strategies should be employed according to reperfusion status.
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Affiliation(s)
- B-H Cho
- Department of Neurology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - J-T Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju, Korea
| | - J S Lee
- Clinical Research Center, Asan Medical Center, Seoul, Korea
| | - M-S Park
- Department of Neurology, Chonnam National University Hospital, Gwangju, Korea
| | - K-W Kang
- Department of Neurology, Chonnam National University Hospital, Gwangju, Korea
| | - K-H Choi
- Department of Neurology, Chonnam National University Hospital, Gwangju, Korea
| | - S-H Lee
- Department of Neurology, Chonnam National University Hospital, Gwangju, Korea
| | - S-M Choi
- Department of Neurology, Chonnam National University Hospital, Gwangju, Korea
| | - B C Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju, Korea
| | - M-K Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju, Korea
| | - K-H Cho
- Department of Neurology, Chonnam National University Hospital, Gwangju, Korea
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Teng RS, Tan BY, Miny S, Syn NL, Ho AF, Ngiam NJ, Yeo LL, Choong AM, Sharma VK. Effect of Pretreatment Blood Pressure on Outcomes in Thrombolysed Acute Ischemic Stroke Patients: A Systematic Review and Meta-analysis. J Stroke Cerebrovasc Dis 2019; 28:906-919. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.12.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 11/16/2018] [Accepted: 12/08/2018] [Indexed: 11/26/2022] Open
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Kim TJ, Park HK, Kim JM, Lee JS, Park SH, Jeong HB, Park KY, Rha JH, Yoon BW, Ko SB. Blood pressure variability and hemorrhagic transformation in patients with successful recanalization after endovascular recanalization therapy: A retrospective observational study. Ann Neurol 2019; 85:574-581. [PMID: 30761582 DOI: 10.1002/ana.25434] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 02/11/2019] [Accepted: 02/12/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Although blood pressure (BP) variability has been regarded as a risk factor for hemorrhagic transformation (HTF) after intravenous thrombolysis, its effect on HTF after endovascular recanalization therapy (ERT) remains to be elucidated. We aimed to study the relationship between BP variability and symptomatic intracerebral hemorrhage (sICH) after successful recanalization with ERT. METHODS A total of 211 patients with acute ischemic stroke and successful recanalization (thrombolysis in cerebral infarction 2b or 3) after ERT were included between January 2013 and May 2017. The BP data following ERT was obtained over the first 24 hours using parameters including mean, maximum, minimum, difference between maximum and minimum, standard deviation, coefficient of variation, successive variations, and time rate (TR) of BP variation for systolic BP (SBP) and diastolic BP. sICH was defined as parenchymal hemorrhage type 2 with neurological deterioration of 4 points of more on the National Institute of Health Stroke Scale. RESULTS Among the included patients, 20 (9.5%) developed sICH after successful ERT. The parameters linked with BP fluctuation over time were significantly related to sICH. After adjusting for confounders, the TR of SBP (per 0.1 mmHg/min increase) variation was independently associated with sICH (odds ratio = 1.71, 95% confidence interval = 1.013-2.886). INTERPRETATION Time-related BP variability in the first 24 hours following successful ERT was more correlated with sICH than other absolute BP levels. This suggests that maintaining a stable BP may be an important factor in preventing sICH after successful ERT. Ann Neurol 2019;85:574-581.
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Affiliation(s)
- Tae Jung Kim
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hee-Kwon Park
- Department of Neurology, Inha University School of Medicine, Incheon, Republic of Korea
| | - Jeong-Min Kim
- Department of Neurology, Chung Ang University Hospital, Seoul, Republic of Korea
| | - Ji Sung Lee
- Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea
| | - Soo-Hyun Park
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hae-Bong Jeong
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kwang-Yeol Park
- Department of Neurology, Chung Ang University Hospital, Seoul, Republic of Korea
| | - Joung-Ho Rha
- Department of Neurology, Inha University School of Medicine, Incheon, Republic of Korea
| | - Byung-Woo Yoon
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sang-Bae Ko
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
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Malhotra K, Ahmed N, Filippatou A, Katsanos AH, Goyal N, Tsioufis K, Manios E, Pikilidou M, Schellinger PD, Alexandrov AW, Alexandrov AV, Tsivgoulis G. Association of Elevated Blood Pressure Levels with Outcomes in Acute Ischemic Stroke Patients Treated with Intravenous Thrombolysis: A Systematic Review and Meta-Analysis. J Stroke 2019; 21:78-90. [PMID: 30732443 PMCID: PMC6372893 DOI: 10.5853/jos.2018.02369] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 11/23/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND PURPOSE Although arbitrary blood pressure (BP) thresholds exist for acute ischemic stroke (AIS) patients eligible for intravenous thrombolysis (IVT), current international recommendations lack clarity on the impact of mean pre- and post-IVT BP levels on clinical outcomes. METHODS Eligible studies involving IVT-treated AIS patients were identified that reported the association of mean systolic BP (SBP) or diastolic BP levels before and after IVT with the following outcomes: 3-month favorable functional outcome (modified Rankin Scale [mRS] scores of 0-1) and 3-month functional independence (mRS scores of 0-2), 3-month mortality and symptomatic intracranial hemorrhage (sICH). Unadjusted analyses of standardized mean differences and adjusted analyses of studies reporting odds ratios (ORadj) per 10 mm Hg BP increment were performed using random-effects models. RESULTS We identified 26 studies comprising 56,513 patients. Higher pre- (P=0.02) and posttreatment (P=0.006) SBP levels were observed in patients with sICH. Patients with 3-month functional independence had lower post-treatment (P<0.001) SBP whereas trended towards lower pre-treatment (P=0.06) SBP. In adjusted analyses, elevated pre- (ORadj, 1.08; 95% confidence interval [CI], 1.01 to 1.16) and post-treatment (ORadj, 1.13; 95% CI, 1.01 to 1.25) SBP levels were associated with increased likelihood of sICH. Increasing pre- (ORadj, 0.91; 95% CI, 0.84 to 0.98) and post-treatment (ORadj, 0.70; 95% CI, 0.57 to 0.87) SBP values were also related to lower odds of 3-month functional independence. CONCLUSION s We found that elevated BP levels adversely impact AIS outcomes in patients receiving IVT. Future randomized-controlled clinical trials will provide definitive data on the aforementioned association.
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Affiliation(s)
- Konark Malhotra
- Department of Neurology, West Virginia University-Charleston Division, Charleston, WV, USA
| | - Niaz Ahmed
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Angeliki Filippatou
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Aristeidis H Katsanos
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Konstantinos Tsioufis
- First Cardiology Clinic, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Efstathios Manios
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Maria Pikilidou
- First Department of Internal Medicine, Hypertension Excellence Center, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Peter D Schellinger
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany
| | - Anne W Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
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Buonacera A, Stancanelli B, Malatino L. Stroke and Hypertension: An Appraisal from Pathophysiology to Clinical Practice. Curr Vasc Pharmacol 2018; 17:72-84. [DOI: 10.2174/1570161115666171116151051] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 09/25/2017] [Accepted: 10/05/2017] [Indexed: 01/04/2023]
Abstract
Stroke as a cause of long-term disability is a growing public health burden. Therefore, focusing
on prevention is important. The most prominent aim of this strategy is to treat modifiable risk factors,
such as arterial hypertension, the leading modifiable contributor to stroke. Thus, efforts to adequately
reduce Blood Pressure (BP) among hypertensives are mandatory. In this respect, although safety
and benefits of BP control related to long-term outcome have been largely demonstrated, there are open
questions that remain to be addressed, such as optimal timing to initiate BP reduction and BP goals to be
targeted. Moreover, evidence on antihypertensive treatment during the acute phase of stroke or BP management
in specific categories (i.e. patients with carotid stenosis and post-acute stroke) remain controversial.
</P><P>
This review provides a critical update on the current knowledge concerning BP management and stroke
pathophysiology in patients who are either at risk for stroke or who experienced stroke.
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Affiliation(s)
- Agata Buonacera
- Academic Unit of Internal Medicine and Hypertension Centre, Department of Clinical and Experimental Medicine, University of Catania, c/o Cannizzaro Hospital, Catania, Italy
| | - Benedetta Stancanelli
- Academic Unit of Internal Medicine and Hypertension Centre, Department of Clinical and Experimental Medicine, University of Catania, c/o Cannizzaro Hospital, Catania, Italy
| | - Lorenzo Malatino
- Academic Unit of Internal Medicine and Hypertension Centre, Department of Clinical and Experimental Medicine, University of Catania, c/o Cannizzaro Hospital, Catania, Italy
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Allan PD, Tzeng YC, Gowing EK, Clarkson AN, Fan JL. Dietary nitrate supplementation reduces low frequency blood pressure fluctuations in rats following distal middle cerebral artery occlusion. J Appl Physiol (1985) 2018; 125:862-869. [DOI: 10.1152/japplphysiol.01081.2017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
It is known that high blood pressure variability (BPV) in acute ischemic stroke is associated with adverse outcomes, yet there are no therapeutic treatments to reduce BPV. Studies have found increasing nitric oxide (NO) bioavailability improves neurological function following stroke, but whether dietary nitrate supplementation could reduce BPV remains unknown. We investigated the effects of dietary nitrate supplementation on heart rate (HR), blood pressure (BP), and beat-to-beat BPV using wireless telemetry in a rat model of distal middle cerebral artery occlusion. Blood pressure variability was characterized by spectral power analysis in the low frequency (LF; 0.2–0.6 Hz) range prestroke and during the 7 days poststroke in a control group ( n = 8) and a treatment group ( n = 8, 183 mg/l sodium nitrate in drinking water). Dietary nitrate supplementation moderately reduced systolic BPV in the LF range by ~11% compared with the control group ( P = 0.03), while resting BP and HR were not different between the two groups ( P = 0.28 and 0.33, respectively). Despite systolic BPV being reduced with dietary nitrate, we found no difference in infarct volumes between the treatment and the control groups (1.59 vs. 1.62 mm3, P = 0.86). These findings indicate that dietary nitrate supplementation is effective in reducing systolic BPV following stroke without affecting absolute BP. In light of mounting evidence linking increased BPV with poor stroke patient outcome, our data support the role of dietary nitrate as an adjunct treatment following ischemic stroke. NEW & NOTEWORTHY Using a rat model of stroke, we found that dietary nitrate supplementation reduced low frequency blood pressure fluctuations following stroke without affecting absolute blood pressure values. Since blood pressure fluctuations are associated with poor clinical outcome in stroke patients, our findings indicate that dietary nitrate could be an effective strategy for reducing blood pressure fluctuations, which could help reduce stroke severity and improve patient recovery.
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Affiliation(s)
- Philip D. Allan
- Department of Surgery and Anaesthesia, Centre for Translational Physiology, University of Otago, Wellington, New Zealand
- Wellington Medical Technology Group, Department of Surgery & Anaesthesia, University of Otago, Wellington, New Zealand
| | - Yu-Chieh Tzeng
- Department of Surgery and Anaesthesia, Centre for Translational Physiology, University of Otago, Wellington, New Zealand
- Wellington Medical Technology Group, Department of Surgery & Anaesthesia, University of Otago, Wellington, New Zealand
| | - Emma K. Gowing
- Department of Anatomy, Brain Health Research Centre and Brain Research New Zealand, University of Otago, Dunedin, New Zealand
| | - Andrew N. Clarkson
- Department of Anatomy, Brain Health Research Centre and Brain Research New Zealand, University of Otago, Dunedin, New Zealand
- Faculty of Pharmacy, The University of Sydney, New South Wales, Australia
| | - Jui-Lin Fan
- Department of Surgery and Anaesthesia, Centre for Translational Physiology, University of Otago, Wellington, New Zealand
- Wellington Medical Technology Group, Department of Surgery & Anaesthesia, University of Otago, Wellington, New Zealand
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Tan Z, Meng H, Dong D, Zhao Y, Xu A. Blood pressure variability estimated by ARV is a predictor of poor short-term outcomes in a prospective cohort of minor ischemic stroke. PLoS One 2018; 13:e0202317. [PMID: 30142202 PMCID: PMC6108465 DOI: 10.1371/journal.pone.0202317] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 08/01/2018] [Indexed: 11/25/2022] Open
Abstract
Prior studies have shown that patients with minor ischemic stroke have substantial disability rates at hospital discharge. We sought to determine whether blood pressure variability (BPV) estimated by average real variability (ARV) is one of the predictors of poor outcome at 90 days. Four hundred fifty-one consecutive patients with ischemic stroke treated within 7 days after onset were enrolled prospectively. Baseline magnetic resonance imaging (MRI) was performed on all subjects. Blood pressure was measured for all recruited patients every 2 hours in the first 24 hours after admission, followed by measurements collected every 4 hours from day 2 to day 7 after admission. ARV was used to estimate BPV. A total of 192 patients with minor ischemic stroke were enrolled, and 11 of them (5.7%) had poor outcomes. Univariate regression analysis showed that early neurological deterioration (X2 = 21.44, P = 0.000), severe symptomatic large artery stenosis or occlusion (X2 = 9.260, P = 0.000), large artery atherosclerotic stroke (X2 = 7.14, P = 0.002), total cholesterol (TC), and D2-7 SBP-ARV (t = 5.449, P = 0.001) of the poor outcome group were significantly higher than those of the good outcome group. Multivariate logistic regression analysis showed that early neurological deterioration (OR 4.369, 95% CI 3.54, 15.65; P = 0.001), severe symptomatic large artery stenosis or occlusion (OR 5.56, 95% CI 3.56, 13.65; P = 0.000), large artery atherosclerotic stroke (OR 3.56, 95% CI 1.45, 7.48; P = 0.004), and D2-7 SBP-ARV (OR 3.96, 95% CI 1.90, 20.18, P = 0.008) were significantly related to poor outcomes. In conclusion, approximately 5.7% of minor ischemic stroke patients had poor outcomes. D2-7 SBP-ARV, early neurologic deterioration, severe symptomatic artery stenosis or occlusion, and large atherosclerotic stroke were the independent risk factors of poor short-term outcomes.
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Affiliation(s)
- Zefeng Tan
- Department of Neurology, the First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, China
| | - Heng Meng
- Department of Neurology, the First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, China
| | - Dawei Dong
- Department of Neurology, the First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, China
| | - Ying Zhao
- Department of Neurology, the First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, China
| | - Anding Xu
- Department of Neurology, the First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, China
- * E-mail:
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Wang YF, Li JX, Sun XS, Lai R, Sheng WL. High serum uric acid levels are a protective factor against unfavourable neurological functional outcome in patients with ischaemic stroke. J Int Med Res 2018. [PMID: 29529907 PMCID: PMC5991245 DOI: 10.1177/0300060517752996] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objective We aimed to evaluate the association between serum uric acid levels at the onset and prognostic outcome in patients with acute ischaemic stroke. Methods We retrospectively analysed the outcomes of 1166 patients with ischaemic stroke who were hospitalized in our centre during August 2008 to November 2012. Correlations of serum uric acid levels and prognostic outcomes were analysed. Results Men had higher serum uric acid levels and better neurological functional outcomes compared with women. There was a strong negative correlation between serum uric acid levels and unfavourable neurological functional outcomes. Generalized estimated equation analysis showed that a higher serum uric acid level (>237 µmol/L) was a protective factor for neurological functional outcome in male, but not female, patients. Among five trial of ORG 10172 in acute stroke treatment classification subtypes, only patients with the large-artery atherosclerosis subtype had a significant protective effect of serum uric acid levels on neurological outcome. Conclusions Our study shows that high serum uric acid levels are a significant protective factor in men and in the large-artery atherosclerosis subtype in patients with ischaemic stroke. This is helpful for determining the prognostic value of serum uric acid levels for neurological outcome of acute ischaemic stroke.
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Affiliation(s)
- Yu-Fang Wang
- Neurology Department, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jiao-Xing Li
- Neurology Department, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xun-Sha Sun
- Neurology Department, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Rong Lai
- Neurology Department, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wen-Li Sheng
- Neurology Department, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Chung PW, Kim JT, Sanossian N, Starkmann S, Hamilton S, Gornbein J, Conwit R, Eckstein M, Pratt F, Stratton S, Liebeskind DS, Saver JL. Association Between Hyperacute Stage Blood Pressure Variability and Outcome in Patients With Spontaneous Intracerebral Hemorrhage. Stroke 2018; 49:348-354. [PMID: 29301973 DOI: 10.1161/strokeaha.117.017701] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 10/05/2017] [Accepted: 10/12/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Increased blood pressure (BP) variability, in addition to high BP, may contribute to adverse outcome in intracerebral hemorrhage. However, degree and association with outcome of BP variability (BPV) in the hyperacute period, 15 minutes to 5 hours after onset, have not been delineated. METHODS Among consecutive patients with intracerebral hemorrhage enrolled in the FAST-MAG trial (Field Administration of Stroke Therapy-Magnesium), BPs were recorded by paramedics in the field and during the first 24 hours of hospital course. BP was analyzed in the hyperacute period, from 0 to 4-6 hours, and in the acute period, from 0 to 24-26 hours after onset. BPV was analyzed by SD, coefficient of variation, and successive variation. RESULTS Among 386 patients with intracerebral hemorrhage, first systolic BP at median 23 minutes (interquartile range, 14-38.5) after onset was median 176 mm Hg, second systolic BP on emergency department arrival at 57 minutes (interquartile range, 45-75) after onset was 178 mm Hg, and systolic BP 24 hours after arrival was 138 mm Hg. Unfavorable outcome at 3 months (modified Rankin Scale, 3-6) occurred in 270 (69.9%). Neither mean nor maximum systolic BP was associated with outcome in multivariable analysis. However, all 3 parameters of BPV, in both the hyperacute and the acute stages, were associated with poor outcome. In the hyperacute phase, BPV was associated with poor outcome with adjusted odds ratios of 3.73 for the highest quintile of SD, 4.78 for the highest quintile of coefficient of variation, and 3.39 for the highest quintile of successive variation. CONCLUSIONS BPV during the hyperacute first minutes and hours after onset in patients with intracerebral hemorrhage was independently associated with poor functional outcome. Stabilization of BPV during this vulnerable period, in the pre-hospital and early emergency department course, is a potential therapeutic target for future clinical trials. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00059332.
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Affiliation(s)
- Pil-Wook Chung
- From the Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, University of Southern California, Los Angeles (N.S.); Comprehensive Stroke Center, Division of Emergency Medicine, and Department of Neurology (S.S.), Department of Biomathematics (J.G.), and Comprehensive Stroke Center and Department of Neurology (D.S.L., J.L.S.), David Geffen School of Medicine, University of California, Los Angeles; School of Medicine, Stanford University, CA (S.H.); National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California, Los Angeles (M.E.); Los Angeles Fire Department, CA (M.E.); Los Angeles County Department of Public Health, CA (F.P.); and Department of Emergency Medicine, Los Angeles EMS Agency, Orange County EMS Agency, Harbor-University of California, Los Angeles Medical Center (S.S.).
| | - Joon-Tae Kim
- From the Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, University of Southern California, Los Angeles (N.S.); Comprehensive Stroke Center, Division of Emergency Medicine, and Department of Neurology (S.S.), Department of Biomathematics (J.G.), and Comprehensive Stroke Center and Department of Neurology (D.S.L., J.L.S.), David Geffen School of Medicine, University of California, Los Angeles; School of Medicine, Stanford University, CA (S.H.); National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California, Los Angeles (M.E.); Los Angeles Fire Department, CA (M.E.); Los Angeles County Department of Public Health, CA (F.P.); and Department of Emergency Medicine, Los Angeles EMS Agency, Orange County EMS Agency, Harbor-University of California, Los Angeles Medical Center (S.S.)
| | - Nerses Sanossian
- From the Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, University of Southern California, Los Angeles (N.S.); Comprehensive Stroke Center, Division of Emergency Medicine, and Department of Neurology (S.S.), Department of Biomathematics (J.G.), and Comprehensive Stroke Center and Department of Neurology (D.S.L., J.L.S.), David Geffen School of Medicine, University of California, Los Angeles; School of Medicine, Stanford University, CA (S.H.); National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California, Los Angeles (M.E.); Los Angeles Fire Department, CA (M.E.); Los Angeles County Department of Public Health, CA (F.P.); and Department of Emergency Medicine, Los Angeles EMS Agency, Orange County EMS Agency, Harbor-University of California, Los Angeles Medical Center (S.S.)
| | - Sidney Starkmann
- From the Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, University of Southern California, Los Angeles (N.S.); Comprehensive Stroke Center, Division of Emergency Medicine, and Department of Neurology (S.S.), Department of Biomathematics (J.G.), and Comprehensive Stroke Center and Department of Neurology (D.S.L., J.L.S.), David Geffen School of Medicine, University of California, Los Angeles; School of Medicine, Stanford University, CA (S.H.); National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California, Los Angeles (M.E.); Los Angeles Fire Department, CA (M.E.); Los Angeles County Department of Public Health, CA (F.P.); and Department of Emergency Medicine, Los Angeles EMS Agency, Orange County EMS Agency, Harbor-University of California, Los Angeles Medical Center (S.S.)
| | - Scott Hamilton
- From the Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, University of Southern California, Los Angeles (N.S.); Comprehensive Stroke Center, Division of Emergency Medicine, and Department of Neurology (S.S.), Department of Biomathematics (J.G.), and Comprehensive Stroke Center and Department of Neurology (D.S.L., J.L.S.), David Geffen School of Medicine, University of California, Los Angeles; School of Medicine, Stanford University, CA (S.H.); National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California, Los Angeles (M.E.); Los Angeles Fire Department, CA (M.E.); Los Angeles County Department of Public Health, CA (F.P.); and Department of Emergency Medicine, Los Angeles EMS Agency, Orange County EMS Agency, Harbor-University of California, Los Angeles Medical Center (S.S.)
| | - Jeffrey Gornbein
- From the Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, University of Southern California, Los Angeles (N.S.); Comprehensive Stroke Center, Division of Emergency Medicine, and Department of Neurology (S.S.), Department of Biomathematics (J.G.), and Comprehensive Stroke Center and Department of Neurology (D.S.L., J.L.S.), David Geffen School of Medicine, University of California, Los Angeles; School of Medicine, Stanford University, CA (S.H.); National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California, Los Angeles (M.E.); Los Angeles Fire Department, CA (M.E.); Los Angeles County Department of Public Health, CA (F.P.); and Department of Emergency Medicine, Los Angeles EMS Agency, Orange County EMS Agency, Harbor-University of California, Los Angeles Medical Center (S.S.)
| | - Robin Conwit
- From the Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, University of Southern California, Los Angeles (N.S.); Comprehensive Stroke Center, Division of Emergency Medicine, and Department of Neurology (S.S.), Department of Biomathematics (J.G.), and Comprehensive Stroke Center and Department of Neurology (D.S.L., J.L.S.), David Geffen School of Medicine, University of California, Los Angeles; School of Medicine, Stanford University, CA (S.H.); National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California, Los Angeles (M.E.); Los Angeles Fire Department, CA (M.E.); Los Angeles County Department of Public Health, CA (F.P.); and Department of Emergency Medicine, Los Angeles EMS Agency, Orange County EMS Agency, Harbor-University of California, Los Angeles Medical Center (S.S.)
| | - Marc Eckstein
- From the Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, University of Southern California, Los Angeles (N.S.); Comprehensive Stroke Center, Division of Emergency Medicine, and Department of Neurology (S.S.), Department of Biomathematics (J.G.), and Comprehensive Stroke Center and Department of Neurology (D.S.L., J.L.S.), David Geffen School of Medicine, University of California, Los Angeles; School of Medicine, Stanford University, CA (S.H.); National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California, Los Angeles (M.E.); Los Angeles Fire Department, CA (M.E.); Los Angeles County Department of Public Health, CA (F.P.); and Department of Emergency Medicine, Los Angeles EMS Agency, Orange County EMS Agency, Harbor-University of California, Los Angeles Medical Center (S.S.)
| | - Frank Pratt
- From the Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, University of Southern California, Los Angeles (N.S.); Comprehensive Stroke Center, Division of Emergency Medicine, and Department of Neurology (S.S.), Department of Biomathematics (J.G.), and Comprehensive Stroke Center and Department of Neurology (D.S.L., J.L.S.), David Geffen School of Medicine, University of California, Los Angeles; School of Medicine, Stanford University, CA (S.H.); National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California, Los Angeles (M.E.); Los Angeles Fire Department, CA (M.E.); Los Angeles County Department of Public Health, CA (F.P.); and Department of Emergency Medicine, Los Angeles EMS Agency, Orange County EMS Agency, Harbor-University of California, Los Angeles Medical Center (S.S.)
| | - Sam Stratton
- From the Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, University of Southern California, Los Angeles (N.S.); Comprehensive Stroke Center, Division of Emergency Medicine, and Department of Neurology (S.S.), Department of Biomathematics (J.G.), and Comprehensive Stroke Center and Department of Neurology (D.S.L., J.L.S.), David Geffen School of Medicine, University of California, Los Angeles; School of Medicine, Stanford University, CA (S.H.); National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California, Los Angeles (M.E.); Los Angeles Fire Department, CA (M.E.); Los Angeles County Department of Public Health, CA (F.P.); and Department of Emergency Medicine, Los Angeles EMS Agency, Orange County EMS Agency, Harbor-University of California, Los Angeles Medical Center (S.S.)
| | - David S Liebeskind
- From the Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, University of Southern California, Los Angeles (N.S.); Comprehensive Stroke Center, Division of Emergency Medicine, and Department of Neurology (S.S.), Department of Biomathematics (J.G.), and Comprehensive Stroke Center and Department of Neurology (D.S.L., J.L.S.), David Geffen School of Medicine, University of California, Los Angeles; School of Medicine, Stanford University, CA (S.H.); National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California, Los Angeles (M.E.); Los Angeles Fire Department, CA (M.E.); Los Angeles County Department of Public Health, CA (F.P.); and Department of Emergency Medicine, Los Angeles EMS Agency, Orange County EMS Agency, Harbor-University of California, Los Angeles Medical Center (S.S.)
| | - Jeffrey L Saver
- From the Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, University of Southern California, Los Angeles (N.S.); Comprehensive Stroke Center, Division of Emergency Medicine, and Department of Neurology (S.S.), Department of Biomathematics (J.G.), and Comprehensive Stroke Center and Department of Neurology (D.S.L., J.L.S.), David Geffen School of Medicine, University of California, Los Angeles; School of Medicine, Stanford University, CA (S.H.); National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California, Los Angeles (M.E.); Los Angeles Fire Department, CA (M.E.); Los Angeles County Department of Public Health, CA (F.P.); and Department of Emergency Medicine, Los Angeles EMS Agency, Orange County EMS Agency, Harbor-University of California, Los Angeles Medical Center (S.S.)
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29
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Zhang Y, Wang H, Xu K, Wang P, Li XY, Zhao JB, Tang Y. Ambulatory blood pressure variability within the first 24 hours after admission and outcomes of acute ischemic stroke. ACTA ACUST UNITED AC 2018; 12:195-203. [PMID: 29396105 DOI: 10.1016/j.jash.2017.12.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 12/02/2017] [Accepted: 12/22/2017] [Indexed: 10/18/2022]
Abstract
Our purpose was to evaluate the value of blood pressure variability within the first 24 hours after admission in predicting outcomes of patients with acute ischemic stroke (AIS). A greater variability in systolic blood pressure (adjusted odds ratio [OR] = 1.801, 95% confidence interval [CI] = 1.167-2.779) was associated with poor discharge outcome, especially for nondiabetics (adjusted OR = 1.948, 95% CI = 1.184-3.205) and cardioembolism-related patients with AIS (OR = 7.650, 95% CI = 1.370-42.713). However, this correlation was not observed with a long-term (3-month or 6-month) outcome in patients with AIS. There was no association between diastolic blood pressure variability within the first 24 hours after admission and outcome. In conclusion, systolic blood pressure variability within the first 24 hours after admission is a critical predictor for short-term outcome of patients with AIS.
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Affiliation(s)
- Yu Zhang
- Department of Epidemiology, School of Public Health, Harbin Medical University, Harbin, Heilongjiang Province, P. R. China
| | - Hong Wang
- Department of Epidemiology, School of Public Health, Harbin Medical University, Harbin, Heilongjiang Province, P. R. China
| | - Ke Xu
- Department of Epidemiology, School of Public Health, Harbin Medical University, Harbin, Heilongjiang Province, P. R. China
| | - Ping Wang
- Department of Epidemiology, School of Public Health, Harbin Medical University, Harbin, Heilongjiang Province, P. R. China
| | - Xin-Yan Li
- Department of Epidemiology, School of Public Health, Harbin Medical University, Harbin, Heilongjiang Province, P. R. China
| | - Jing-Bo Zhao
- Department of Epidemiology, School of Public Health, Harbin Medical University, Harbin, Heilongjiang Province, P. R. China.
| | - Ying Tang
- Department of Neurology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, P. R. China.
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30
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Bonardo P, Pantiu F, Chertcoff A, León Cejas L, Pacha S, Uribe Roca C, Ernst G, Fernández Pardal M, Reisin R. Blood pressure evolution in young patients with acute ischemic stroke: a new model for understanding the natural course of spontaneous hypertension? Int J Neurosci 2017; 128:140-145. [PMID: 28889789 DOI: 10.1080/00207454.2017.1378198] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Approximately 80% of patients suffering an acute ischemic stroke develop transient hypertension. The physiopathological mechanism remains unclear. Due to the lack of vascular risk factors, young adults could be a useful model for understanding blood pressure (BP) evolution in this setting. METHODS Patients between 18 and 55 years old admitted with an acute ischemic stroke were included. BP was evaluated during the following 48 h. Hypertension was defined as: systolic blood pressure (SBP) ≥140 mmHg or diastolic blood pressure (DBP) ≥90 mmHg. Patients were divided into two groups: RF group included those who had a previous vascular risk factor and/or other medical condition known to affect the autonomic function; noRF group included patients without any of the previously stated conditions. RESULTS Thirty-nine patients were included: mean age: 44.26 years old, 21 were males (53.8%). Mean SBP and DBP at admission were 139.77 ± 5.35 mmHg (range: 90-243) and 84.44 ± 3.02 mmHg (range: 60-128), respectively; 43.58% patients were hypertensive at admission. SBP decreased significantly during the first 48 h (p = 0.044) for the entire population. RF group has higher SBP (p = 0.009) and DBP (p = 0.011) at admission than the noRF group. CONCLUSION Most patients were normotensive at admission and BP fell spontaneously despite BP at admission. Young patients without medical conditions that could alter the autonomic system function could be a useful model for understanding acute hypertension in ischemic stroke.
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Affiliation(s)
- Pablo Bonardo
- a Neurology Department , Hospital Británico de Buenos Aires , Buenos Aires , Argentina
| | - Fatima Pantiu
- a Neurology Department , Hospital Británico de Buenos Aires , Buenos Aires , Argentina
| | - Anibal Chertcoff
- a Neurology Department , Hospital Británico de Buenos Aires , Buenos Aires , Argentina
| | - Luciana León Cejas
- a Neurology Department , Hospital Británico de Buenos Aires , Buenos Aires , Argentina
| | - Sol Pacha
- a Neurology Department , Hospital Británico de Buenos Aires , Buenos Aires , Argentina
| | - Claudia Uribe Roca
- a Neurology Department , Hospital Británico de Buenos Aires , Buenos Aires , Argentina
| | - Glenda Ernst
- a Neurology Department , Hospital Británico de Buenos Aires , Buenos Aires , Argentina
| | | | - Ricardo Reisin
- a Neurology Department , Hospital Británico de Buenos Aires , Buenos Aires , Argentina
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31
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Starr JB, Tirschwell DL, Becker KJ. Labetalol Use Is Associated With Increased In-Hospital Infection Compared With Nicardipine Use in Intracerebral Hemorrhage. Stroke 2017; 48:2693-2698. [DOI: 10.1161/strokeaha.117.017230] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 08/15/2017] [Accepted: 08/16/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Jordan B. Starr
- From the Departments of Anesthesiology and Pain Medicine (J.B.S.) and Neurology (D.L.T., K.J.B.), University of Washington, Seattle
| | - David L. Tirschwell
- From the Departments of Anesthesiology and Pain Medicine (J.B.S.) and Neurology (D.L.T., K.J.B.), University of Washington, Seattle
| | - Kyra J. Becker
- From the Departments of Anesthesiology and Pain Medicine (J.B.S.) and Neurology (D.L.T., K.J.B.), University of Washington, Seattle
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32
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Cai K, Zhang Y, Shen L, Ji Q, Xu T, Cao M. Characteristics of Blood Pressure Profiles After Endovascular Coiling as Predictors of Clinical Outcome in Poor-Grade Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2017; 104:459-466. [DOI: 10.1016/j.wneu.2017.05.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 05/01/2017] [Accepted: 05/04/2017] [Indexed: 10/19/2022]
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33
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Xu B, Ji Q, Zhang Y, Shen L, Cao M, Cai K. Postoperative blood pressure variability exerts an influence on clinical outcome after coil embolization of ruptured intracranial aneurysms. Neurol Res 2017; 39:813-818. [PMID: 28675964 DOI: 10.1080/01616412.2017.1348653] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Bin Xu
- Department of Neurology, Affiliated Hospital of Nantong University, Nantong, China
| | - Qiuhong Ji
- Department of Neurology, Affiliated Hospital of Nantong University, Nantong, China
| | - Yunfeng Zhang
- Department of Neurology, Affiliated Hospital of Nantong University, Nantong, China
| | - Lihua Shen
- Department of Neurology, Affiliated Hospital of Nantong University, Nantong, China
| | - Maohong Cao
- Department of Neurology, Affiliated Hospital of Nantong University, Nantong, China
| | - Kefu Cai
- Department of Neurology, Affiliated Hospital of Nantong University, Nantong, China
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34
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Milonas D, Tziomalos K. Blood Pressure Variability: Does it Predict the Outcome of Acute Ischemic Stroke? Am J Hypertens 2017; 30:476-477. [PMID: 28199999 DOI: 10.1093/ajh/hpx019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 02/02/2017] [Indexed: 11/12/2022] Open
Affiliation(s)
- Dimitrios Milonas
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Konstantinos Tziomalos
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
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35
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Xia Y, Wu D, Gao Z, Liu X, Chen Q, Ren L, Wu W. Association between beat-to-beat blood pressure variability and vascular elasticity in normal young adults during the cold pressor test. Medicine (Baltimore) 2017; 96:e6000. [PMID: 28225488 PMCID: PMC5348138 DOI: 10.1097/md.0000000000006000] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The beat-to-beat blood pressure (BP) monitoring parameters, such as average beat-to-beat BP, BP variability (BPV), could have an influence on the vascular elasticity. This study hypothesized that the elevated beat-to-beat BPV could evoke the reduction of the vascular elasticity independent of BP levels. We measured the beat-to-beat BP recordings and total arterial compliance (TAC), which was used to assess the vascular elasticity, in 80 young healthy adults during the cold pressor test (CPT). The CPT included 3 phases: baseline phase, cold stimulus phase, recovery phase. Six parameters were used to estimate BPV. In bivariate correlation analysis, TAC showed a significant correlation with systolic BP (SBP) and diastolic BP (DBP) in the cold stimulus phase; and 4 indices of SBP variability (SBPV) were associated with TAC (r = 0.271∼0.331, P ≤ 0.015) in the recovery phase; similarly, 2 indices of DBP variability (DBPV) were also correlated with TAC (r = 0.221∼0.285, P ≤ 0.048) in the recovery phase. In multivariate regression analysis, DBPV (β = 0.229, P = 0.001) was a determinant of TAC independent of average DBP, sex, and weight. In addition, both beat-to-beat BP and BPV values increased in the cold stimulus phase (P < 0.01); whereas, the TAC decreased in the cold stimulus phase (P < 0.01). In conclusion, these data suggest that the beat-to-beat DBPV shows an independent association with the vascular elasticity in young normal adults during the CPT.
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Affiliation(s)
- Yufa Xia
- Research Center for Biomedical Information Technology, Shenzhen Institute of Advance Technology, Chinese Academic of Science
| | - Dan Wu
- Research Center for Biomedical Information Technology, Shenzhen Institute of Advance Technology, Chinese Academic of Science
- Shenzhen College of Advanced Technology, University of Chinese Academy of Sciences,Shenzhen University Town, Shenzhen, China
| | - Zhifan Gao
- Research Center for Biomedical Information Technology, Shenzhen Institute of Advance Technology, Chinese Academic of Science
- Shenzhen College of Advanced Technology, University of Chinese Academy of Sciences,Shenzhen University Town, Shenzhen, China
| | - Xin Liu
- Research Center for Biomedical Information Technology, Shenzhen Institute of Advance Technology, Chinese Academic of Science
| | | | - Lijie Ren
- Department of Neurology, Shenzhen Second People's Hospital, Futian District
| | - Wanqing Wu
- Research Center for Biomedical Information Technology, Shenzhen Institute of Advance Technology, Chinese Academic of Science
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36
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Waltimo T, Haapaniemi E, Surakka IL, Melkas S, Sairanen T, Sibolt G, Tatlisumak T, Strbian D. Post-thrombolytic blood pressure and symptomatic intracerebral hemorrhage. Eur J Neurol 2016; 23:1757-1762. [DOI: 10.1111/ene.13118] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 07/11/2016] [Indexed: 11/28/2022]
Affiliation(s)
- T. Waltimo
- Department of Neurology; Helsinki University Central Hospital; Helsinki
| | - E. Haapaniemi
- Department of Neurology; Helsinki University Central Hospital; Helsinki
| | - I. L. Surakka
- Institute for Molecular Medicine Finland; University of Helsinki; Helsinki Finland
| | - S. Melkas
- Department of Neurology; Helsinki University Central Hospital; Helsinki
| | - T. Sairanen
- Department of Neurology; Helsinki University Central Hospital; Helsinki
| | - G. Sibolt
- Department of Neurology; Helsinki University Central Hospital; Helsinki
| | - T. Tatlisumak
- Institute for Molecular Medicine Finland; University of Helsinki; Helsinki Finland
| | - D. Strbian
- Department of Neurology; Helsinki University Central Hospital; Helsinki
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37
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Tziomalos K, Giampatzis V, Bouziana SD, Spanou M, Kostaki S, Papadopoulou M, Angelopoulou SM, Tsopozidi M, Savopoulos C, Hatzitolios AI. No Association Observed Between Blood Pressure Variability During the Acute Phase of Ischemic Stroke and In-Hospital Outcomes. Am J Hypertens 2016; 29:841-6. [PMID: 26657891 DOI: 10.1093/ajh/hpv191] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 11/16/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Recent data suggest that blood pressure (BP) variability confers increased cardiovascular risk independently of BP. We aimed to evaluate the association between BP variability during the acute phase of ischemic stroke and the in-hospital outcome. METHODS We prospectively studied 608 consecutive patients admitted with acute ischemic stroke (39.5% males, age: 79.1±6.6 years). Variability in BP was assessed with the SD and with the coefficient of variation of systolic (SBP) and diastolic BP (DBP) during the first 2 and the first 3 days of hospitalization. The outcome was assessed with dependency rates at discharge and with in-hospital mortality. RESULTS Patients who were dependent at discharge did not differ from patients who were independent in any index of BP variability. Independent predictors of dependency at discharge were age (relative risk (RR) 1.17, 95% confidence interval (CI) 1.09-1.25, P < 0.001), history of prior ischemic stroke (RR 2.08, 95% CI 1.02-4.24, P = 0.04), and National Institutes of Health Stroke Scale (NIHSS) at admission (RR 1.64, 95% CI 1.44-1.86, P < 0.001). Patients who died during hospitalization did not differ in any index of BP variability from patients who were discharged. DBP at admission was independently and directly associated with in-hospital mortality (RR 1.06, 95% CI 1.03-1.09, P < 0.001). Other independent predictors of in-hospital mortality were history of atrial fibrillation (RR 3.30, 95% CI 1.46-7.49, P = 0.004) and NIHSS at admission (RR 1.18, 95% CI 1.13-1.23, P < 0.001). CONCLUSIONS Our data do not support the hypothesis of an association between BP variability and in-hospital outcomes among patients admitted for ischemic stroke.
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Affiliation(s)
- Konstantinos Tziomalos
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece.
| | - Vasilios Giampatzis
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Stella D Bouziana
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Marianna Spanou
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Stavroula Kostaki
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Maria Papadopoulou
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Stella-Maria Angelopoulou
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Maria Tsopozidi
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Christos Savopoulos
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Apostolos I Hatzitolios
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
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38
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Serrano-Ponz M, Rodrigo-Gasqué C, Siles E, Martínez-Lara E, Ochoa-Callejero L, Martínez A. Temporal profiles of blood pressure, circulating nitric oxide, and adrenomedullin as predictors of clinical outcome in acute ischemic stroke patients. Mol Med Rep 2016; 13:3724-34. [PMID: 27035412 PMCID: PMC4838158 DOI: 10.3892/mmr.2016.5001] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 02/18/2016] [Indexed: 12/12/2022] Open
Abstract
Stroke remains an important health and social challenge. The present study investigated whether blood pressure (BP) parameters and circulating levels of nitric oxide metabolites (NOx) and adrenomedullin (AM) may predict clinical outcomes of stroke. Patients (n=76) diagnosed with acute ischemic stroke were admitted to the stroke unit and clinical history data and monitored parameters were recorded. Blood plasma was collected at days 1, 2, and 7 to measure NOx and AM levels. Infarct volume, neurological severity [on the National Institutes of Health Stroke Scale (NIHSS)], and functional prognosis (on the Rankin scale) were measured as clinical outcomes. Patients with higher BP had more severe symptoms (NIHSS >3; P<0.01) and BP variability predicted neurological severity and growth of infarct volume. NOx values were significantly lower in stroke patients than in healthy controls (P<0.01). An increase in NOx levels from day 1 to day 2 was beneficial for the patients as measured by NIHSS at 7 days and 3 months, and by Rankin at 3 months [odds ratio (OR), 0.91] whereas a steep increase from day 2 to day 7 was detrimental and associated with an increase in infarct volume (OR, 35.3). AM levels were significantly higher in patients at day 1 and 2 than in healthy individuals (P<0.01) and these levels returned to normal at day 7. Patients with high AM levels at day 2 had significantly higher NIHSS scores measured at day 1 (P<0.05) and 7 (P<0.01). A receiving operating characteristic curve analysis identified that AM levels at day 2 of >522.13 pg/ml predicted increased neurological severity at day 7 (area under the curve=0.721). Multivariate logistic regression indicated that AM levels at day 2 predicted increased neurological severity at 7 days and at 3 months. BP parameters and changing levels for NOx and AM predicted long-term clinical outcomes as measured by infarct volume, neurological severity scale, and functional prognosis.
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Affiliation(s)
- Marta Serrano-Ponz
- Stroke Unit, Neurology Service, Hospital San Pedro, 26006 Logroño, Spain
| | | | - Eva Siles
- Experimental Biology Department, University of Jaén, 23071 Jaén, Spain
| | | | - Laura Ochoa-Callejero
- Angiogenesis Group, Oncology Area, Center for Biomedical Research of La Rioja (CIBIR), 26006 Logroño, Spain
| | - Alfredo Martínez
- Angiogenesis Group, Oncology Area, Center for Biomedical Research of La Rioja (CIBIR), 26006 Logroño, Spain
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John S, Hazaa W, Uchino K, Toth G, Bain M, Thebo U, Hussain MS. Lower Intraprocedural Systolic Blood Pressure Predicts Good Outcome in Patients Undergoing Endovascular Therapy for Acute Ischemic Stroke. INTERVENTIONAL NEUROLOGY 2016; 4:151-7. [PMID: 27051411 DOI: 10.1159/000444098] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Accepted: 01/13/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND It is unknown if intraprocedural blood pressure (BP) influences clinical outcomes and what BP parameter best predicts outcomes in acute ischemic stroke (AIS) patients who undergo intra-arterial therapy (IAT) for emergent large vessel occlusion. METHODS We retrospectively reviewed 147 patients who underwent IAT for anterior circulation AIS from January 2008 to December 2012 at our institution. Baseline demographics, stroke treatment variables, and detailed intraprocedural hemodynamic variables were collected. RESULTS The entire cohort consisted of 81 (55%) females with a mean age of 66.9 ± 15.6 years and a median National Institutes of Health Stroke Scale (NIHSS) score of 16 (IQR 11-21). Thirty-six (24.5%) patients died during hospitalization, 25 (17%) achieved a 30-day modified Rankin Scale score of 0-2, and 24 (16.3%) suffered symptomatic parenchymal hematoma type 1/2 hemorrhage. Patients who achieved a good outcome had a significantly lower admission NIHSS score, a higher baseline CT ASPECTS score, and a lower rate of ICA terminus occlusions. Successful recanalization was more frequent in the good-outcome group, while symptomatic hemorrhages occurred only in poor-outcome patients. The first systolic BP (SBP; 146.5 ± 0.2 vs. 157.7 ± 25.6 mm Hg, p = 0.042), first mean arterial pressure (MAP; 98.1 ± 20.8 vs. 109.7 ± 20.3 mm Hg, p = 0.024), maximum SBP (164.6 ± 27.6 vs. 180.9 ± 18.3 mm Hg, p = 0.0003), and maximum MAP (125.5 ± 18.6 vs. 138.5 ± 24.6 mm Hg, p = 0.0309) were all significantly lower in patients who achieved good outcomes. A lower maximum intraprocedural SBP was an independent predictor of good outcome (adjusted OR 0.929, 95% CI 0.886-0.963, p = 0.0005). Initial NIHSS score was the only other independent predictor of a good outcome. CONCLUSION Lower intraprocedural SBP was associated with good outcome in patients undergoing IAT for AIS, and maximum SBP was an independent predictor of good outcome. SBP may be the optimal hemodynamic variable to monitor intraprocedurally during IAT and may predict outcome.
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Affiliation(s)
- Seby John
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Walaa Hazaa
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ken Uchino
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gabor Toth
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mark Bain
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Umera Thebo
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
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40
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Manning LS, Rothwell PM, Potter JF, Robinson TG. Prognostic Significance of Short-Term Blood Pressure Variability in Acute Stroke. Stroke 2015; 46:2482-90. [DOI: 10.1161/strokeaha.115.010075] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 07/02/2015] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Blood pressure variability (BPV) may be an important prognostic factor acutely after stroke. This review investigated the existing evidence for the effect of BPV on outcome after stroke, also considering BPV measurement techniques and definitions.
Methods—
A literature search was performed according to a prespecified study protocol. Two reviewers independently assessed study eligibility and quality. Where appropriate, meta-analyses were performed to assess the effect of BPV on poor functional outcome.
Results—
Eighteen studies from 1359 identified citations were included. Seven studies were included in a meta-analysis for the effect of BPV on functional outcome (death or disability). Systolic BPV was significantly associated with poor functional outcome: pooled odds ratio per 10-mm Hg increment, 1.2; confidence interval (1.1–1.3). A descriptive review of included studies also supports these findings, and in addition, it suggests that systolic BPV may be associated with increased risk of intracranial hemorrhage in those treated with thrombolytic therapy.
Conclusions—
This systematic review and meta-analysis suggest that greater systolic BPV, measured early from ischemic stroke or intracerebral hemorrhage onset, is associated with poor longer-term functional outcome. Future prospective studies should investigate how best to measure and define BPV in acute stroke, as well as to determine its prognostic significance.
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Affiliation(s)
- Lisa S. Manning
- From Department of Cardiovascular Sciences and NIHR Biomedical Research Unit in Cardiovascular Disease, University of Leicester, Leicester, United Kingdom (L.S.M., T.G.R.); Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, United Kingdom (P.M.R.); and Faculty of Medicine and Health Sciences, Norfolk and Norwich Medical School, University of East Anglia, Norwich, United Kingdom (J.F.P.)
| | - Peter M. Rothwell
- From Department of Cardiovascular Sciences and NIHR Biomedical Research Unit in Cardiovascular Disease, University of Leicester, Leicester, United Kingdom (L.S.M., T.G.R.); Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, United Kingdom (P.M.R.); and Faculty of Medicine and Health Sciences, Norfolk and Norwich Medical School, University of East Anglia, Norwich, United Kingdom (J.F.P.)
| | - John F. Potter
- From Department of Cardiovascular Sciences and NIHR Biomedical Research Unit in Cardiovascular Disease, University of Leicester, Leicester, United Kingdom (L.S.M., T.G.R.); Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, United Kingdom (P.M.R.); and Faculty of Medicine and Health Sciences, Norfolk and Norwich Medical School, University of East Anglia, Norwich, United Kingdom (J.F.P.)
| | - Thompson G. Robinson
- From Department of Cardiovascular Sciences and NIHR Biomedical Research Unit in Cardiovascular Disease, University of Leicester, Leicester, United Kingdom (L.S.M., T.G.R.); Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, United Kingdom (P.M.R.); and Faculty of Medicine and Health Sciences, Norfolk and Norwich Medical School, University of East Anglia, Norwich, United Kingdom (J.F.P.)
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Kakaletsis N, Ntaios G, Milionis H, Haidich AB, Makaritsis K, Savopoulos C, Berge E, Hatzitolios AI. Prognostic Value of 24-H ABPM in Acute Ischemic Stroke for Short-, Medium-, and Long-Term Outcome: A Systematic Review and Meta-Analysis. Int J Stroke 2015; 10:1000-7. [DOI: 10.1111/ijs.12609] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Accepted: 06/01/2015] [Indexed: 11/26/2022]
Abstract
Background The association of blood pressure levels during the acute phase of ischemic stroke with outcome remains controversial. Aims The objective of this systematic review is to assess the predictive value for stroke outcome assessed by the modified Rankin scale score of systolic and diastolic blood pressure, measured by ambulatory blood pressure monitoring methods during the acute phase of ischemic stroke, compared with the values of casually derived blood pressure measurement on admission. Methods We searched for studies with patients admitted within 24 h of stroke onset, and who had ambulatory blood pressure monitoring during the first 24 h of admission. We identified studies that reported blood pressure in those with good outcome and in those with poor outcome at end of follow-up, and performed a meta-analysis of the effect of mean blood pressure on outcome. Results High systolic and diastolic blood pressure levels derived with ambulatory blood pressure monitoring were associated with poor short-, medium-, and long-term outcome, but the same was not found for casual blood pressure measurements. An increase in systolic blood pressure of 9·1 mmHg (95% confidence interval: 6·6–11·6, P < 0·001; I2 = 9%) and an increase in diastolic blood pressure of 2·3 mmHg (95% confidence interval: 0·8–3·7, P = 0·002; I2 = 0%) were associated with poor outcome. Conclusions Higher systolic and diastolic blood pressure levels derived with ambulatory blood pressure monitoring were associated with poor outcome. The same was not found for higher casual blood pressure measurements on admission, and it is possible that ambulatory blood pressure monitoring conveys better prognostic information.
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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 Medicine, Medical School, University of Thessaly, Larissa, Greece
| | - Haralampos Milionis
- Department of Internal Medicine, Medical School, University of Ioannina, University Hospital of Ioannina, Ioannina, Greece
| | - Anna-Bettina Haidich
- Department of Hygiene and Epidemiology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Christos Savopoulos
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Eivind Berge
- Department of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | - Apostolos I. Hatzitolios
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
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Zhao M, Zhang L, Wang Z, Wang X, Wang Y, Wei H, Li R, Du Y. Dynamic analysis of blood pressure changes in progressive cerebral infarction. Int Health 2014; 7:293-7. [PMID: 25492947 DOI: 10.1093/inthealth/ihu087] [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] [Received: 02/04/2014] [Accepted: 05/21/2014] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Progressive cerebral infarction is one of the leading causes of high disability and lethality for stroke patients. However, the association between progression of BP changes and cerebral infarction is not currently well understood. METHODS We analyzed the dynamic changes in the BP of patients with acute ischemic stroke and explored the correlation between BP change and cerebral infarction progression. RESULTS 30.9% (30/97) of the patients investigated developed to progressive cerebral infarction 17-141 h after admission. The percentage of patients with a long history of hypertension was significantly higher in the progressive group than in the non-progressive group. The mean systolic BP of the patients 16 h to 5 d after admission was also much higher in the progressive group. A greater abnormality of circadian blood pressure was also observed among patients in the progressive group. CONCLUSIONS Hypertension history of more than 5 years is an important risk factor for progressive cerebral infarction. Both the elevation of systolic blood pressure 16 h to 5 d after admission and abnormal circadian blood pressure are associated with the disease progression.
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Affiliation(s)
- Manli Zhao
- Department of Neurology, Provincial Hospital Affiliated to Shandong University, Jinan 250021, Shandong, PR China Weifang Traditional Chinese Medicine Hospital, Weifang 261041, Shandong, PR China
| | - Lunzhong Zhang
- Weifang Traditional Chinese Medicine Hospital, Weifang 261041, Shandong, PR China
| | - Zeying Wang
- Weifang Traditional Chinese Medicine Hospital, Weifang 261041, Shandong, PR China
| | - Xianglei Wang
- Weifang Traditional Chinese Medicine Hospital, Weifang 261041, Shandong, PR China
| | - Yuyong Wang
- Weifang Traditional Chinese Medicine Hospital, Weifang 261041, Shandong, PR China
| | - Hongyu Wei
- Weifang Traditional Chinese Medicine Hospital, Weifang 261041, Shandong, PR China
| | - Ruihua Li
- Laiwu People's Hospital, Laiwu 271100, Shandong, PR China
| | - Yifeng Du
- Department of Neurology, Shandong Provincial Hospital, Jinan 250021, Shandong, PR China
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43
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Arterial Blood Pressure and Neurologic Outcome After Resuscitation From Cardiac Arrest*. Crit Care Med 2014; 42:2083-91. [DOI: 10.1097/ccm.0000000000000406] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Boan AD, Lackland DT, Ovbiagele B. Lowering of blood pressure for recurrent stroke prevention. Stroke 2014; 45:2506-13. [PMID: 24984744 PMCID: PMC4134881 DOI: 10.1161/strokeaha.114.003666] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 05/28/2014] [Indexed: 01/13/2023]
Affiliation(s)
- Andrea D Boan
- From the Department of Neurosciences, Medical University of South Carolina, Charleston
| | - Daniel T Lackland
- From the Department of Neurosciences, Medical University of South Carolina, Charleston
| | - Bruce Ovbiagele
- From the Department of Neurosciences, Medical University of South Carolina, Charleston.
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45
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Abstract
BACKGROUND Most strokes are due to blockage of an artery in the brain by a blood clot. Prompt treatment with thrombolytic drugs can restore blood flow before major brain damage has occurred and improve recovery after stroke in some people. Thrombolytic drugs, however, can also cause serious bleeding in the brain, which can be fatal. One drug, recombinant tissue plasminogen activator (rt-PA), is licensed for use in selected patients within 4.5 hours of stroke in Europe and within three hours in the USA. There is an upper age limit of 80 years in some countries, and a limitation to mainly non-severe stroke in others. Forty per cent more data are available since this review was last updated in 2009. OBJECTIVES To determine whether, and in what circumstances, thrombolytic therapy might be an effective and safe treatment for acute ischaemic stroke. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (last searched November 2013), MEDLINE (1966 to November 2013) and EMBASE (1980 to November 2013). We also handsearched conference proceedings and journals, searched reference lists and contacted pharmaceutical companies and trialists. SELECTION CRITERIA Randomised trials of any thrombolytic agent compared with control in people with definite ischaemic stroke. DATA COLLECTION AND ANALYSIS Two review authors applied the inclusion criteria, extracted data and assessed trial quality. We verified the extracted data with investigators of all major trials, obtaining additional unpublished data if available. MAIN RESULTS We included 27 trials, involving 10,187 participants, testing urokinase, streptokinase, rt-PA, recombinant pro-urokinase or desmoteplase. Four trials used intra-arterial administration, while the rest used the intravenous route. Most data come from trials that started treatment up to six hours after stroke. About 44% of the trials (about 70% of the participants) were testing intravenous rt-PA. In earlier studies very few of the participants (0.5%) were aged over 80 years; in this update, 16% of participants are over 80 years of age due to the inclusion of IST-3 (53% of participants in this trial were aged over 80 years). Trials published more recently utilised computerised randomisation, so there are less likely to be baseline imbalances than in previous versions of the review. More than 50% of trials fulfilled criteria for high-grade concealment; there were few losses to follow-up for the main outcomes.Thrombolytic therapy, mostly administered up to six hours after ischaemic stroke, significantly reduced the proportion of participants who were dead or dependent (modified Rankin 3 to 6) at three to six months after stroke (odds ratio (OR) 0.85, 95% confidence interval (CI) 0.78 to 0.93). Thrombolytic therapy increased the risk of symptomatic intracranial haemorrhage (OR 3.75, 95% CI 3.11 to 4.51), early death (OR 1.69, 95% CI 1.44 to 1.98; 13 trials, 7458 participants) and death by three to six months after stroke (OR 1.18, 95% CI 1.06 to 1.30). Early death after thrombolysis was mostly attributable to intracranial haemorrhage. Treatment within three hours of stroke was more effective in reducing death or dependency (OR 0.66, 95% CI 0.56 to 0.79) without any increase in death (OR 0.99, 95% CI 0.82 to 1.21; 11 trials, 2187 participants). There was heterogeneity between the trials. Contemporaneous antithrombotic drugs increased the risk of death. Trials testing rt-PA showed a significant reduction in death or dependency with treatment up to six hours (OR 0.84, 95% CI 0.77 to 0.93, P = 0.0006; 8 trials, 6729 participants) with significant heterogeneity; treatment within three hours was more beneficial (OR 0.65, 95% CI 0.54 to 0.80, P < 0.0001; 6 trials, 1779 participants) without heterogeneity. Participants aged over 80 years benefited equally to those aged under 80 years, particularly if treated within three hours of stroke. AUTHORS' CONCLUSIONS Thrombolytic therapy given up to six hours after stroke reduces the proportion of dead or dependent people. Those treated within the first three hours derive substantially more benefit than with later treatment. This overall benefit was apparent despite an increase in symptomatic intracranial haemorrhage, deaths at seven to 10 days, and deaths at final follow-up (except for trials testing rt-PA, which had no effect on death at final follow-up). Further trials are needed to identify the latest time window, whether people with mild stroke benefit from thrombolysis, to find ways of reducing symptomatic intracranial haemorrhage and deaths, and to identify the environment in which thrombolysis may best be given in routine practice.
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Affiliation(s)
- Joanna M Wardlaw
- University of EdinburghCentre for Clinical Brain SciencesThe Chancellor's Building49 Little France CrescentEdinburghUKEH16 4SB
| | - Veronica Murray
- Danderyd HospitalDepartment of Clinical Sciences, Karolinska InstitutetStockholmSwedenSE‐182 88
| | - Eivind Berge
- Oslo University HospitalDepartment of Internal MedicineOsloNorwayNO‐0407
| | - Gregory J del Zoppo
- University of WashingtonDepartment of Medicine (Division of Hematology), Department of Neurology325 Ninth AvenueBox 359756SeattleWashingtonUSA98104
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47
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Goodfellow JA, Dawson J, Quinn TJ. Management of blood pressure in acute stroke. Expert Rev Neurother 2014; 13:911-23. [DOI: 10.1586/14737175.2013.814964] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Oprisiu-Fournier R, Faure S, Mazouz H, Boutitie F, Serot JM, Achard JM, Godefroy O, Hanon O, Temmar M, Albu A, Strandgaard S, Wang J, Black SE, Fournier A. Angiotensin AT1-receptor blockers and cerebrovascular protection: do they actually have a cutting edge over angiotensin-converting enzyme inhibitors? Expert Rev Neurother 2014; 9:1289-305. [DOI: 10.1586/ern.09.88] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Weiss A, Beloosesky Y, Kenett RS, Grossman E. Systolic Blood Pressure During Acute Stroke Is Associated With Functional Status and Long-term Mortality in the Elderly. Stroke 2013; 44:2434-40. [DOI: 10.1161/strokeaha.113.001894] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background and Purpose—
The prognostic value of blood pressure (BP) levels during acute stroke has not been adequately studied. Most studies do not use continuous BP measurements, and patients are followed only for a short period. We designed a study to assess, with 24-hour BP monitoring (24H BPM), the impact of BP levels during the first day of stroke, on the short-term functional status and long-term mortality in elderly patients.
Methods—
We studied 177 patients with acute stroke (89 men), mean age 84±6 years. BP was measured on admission and 24H BPM was recorded within 24 hours of admission. After 7 days, patients were assessed for functional status according to the modified Rankin Scale and were subsequently followed up for mortality ≤5 years (mean, 2.07±1.48).
Results—
After 7 days, functional status improved and modified Rankin Scale decreased from 4.2 to 3.7. Follow-up analysis disclosed that 71 patients (27 men and 44 women) had died. Mortality rate was higher in women (50% versus 30%;
P
<0.01) and in patients with a history of congestive heart failure. Only average systolic BP, recorded by 24H BPM, predicted short-term functional status and long-term mortality. Cox proportional hazards model analysis demonstrated that age, sex, congestive heart failure, and average systolic BP >160 mm Hg, recorded by 24H BPM, were associated with increased mortality.
Conclusions—
High systolic BP recorded by 24H BPM on the first day of stroke was found to be associated with unfavorable short-term functional status and long-term mortality in elderly patients.
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Affiliation(s)
- Avraham Weiss
- From the Geriatric Ward, Rabin Medical Center, Petach Tikvah, Israel (A.W., Y.B.); KPA and Department of Applied Mathematics and Statistics, University of Turin, Turin, Italy (R.S.K.); Department of Internal Medicine D and Hypertension Unit, The Chaim Sheba Medical Center, Tel-Hashomer, Israel (E.G.); and Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel (A.W., Y.B., E.G.)
| | - Yichayaou Beloosesky
- From the Geriatric Ward, Rabin Medical Center, Petach Tikvah, Israel (A.W., Y.B.); KPA and Department of Applied Mathematics and Statistics, University of Turin, Turin, Italy (R.S.K.); Department of Internal Medicine D and Hypertension Unit, The Chaim Sheba Medical Center, Tel-Hashomer, Israel (E.G.); and Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel (A.W., Y.B., E.G.)
| | - Ron S. Kenett
- From the Geriatric Ward, Rabin Medical Center, Petach Tikvah, Israel (A.W., Y.B.); KPA and Department of Applied Mathematics and Statistics, University of Turin, Turin, Italy (R.S.K.); Department of Internal Medicine D and Hypertension Unit, The Chaim Sheba Medical Center, Tel-Hashomer, Israel (E.G.); and Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel (A.W., Y.B., E.G.)
| | - Ehud Grossman
- From the Geriatric Ward, Rabin Medical Center, Petach Tikvah, Israel (A.W., Y.B.); KPA and Department of Applied Mathematics and Statistics, University of Turin, Turin, Italy (R.S.K.); Department of Internal Medicine D and Hypertension Unit, The Chaim Sheba Medical Center, Tel-Hashomer, Israel (E.G.); and Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel (A.W., Y.B., E.G.)
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50
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Tuttolomondo A, Di Raimondo D, Di Sciacca R, Pedone C, La Placa S, Arnao V, Pinto A, Licata G. Effects of clinical and laboratory variables at admission and of in-hospital treatment with cardiovascular drugs on short term prognosis of ischemic stroke. The GIFA study. Nutr Metab Cardiovasc Dis 2013; 23:642-649. [PMID: 22502765 DOI: 10.1016/j.numecd.2012.01.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Revised: 01/19/2012] [Accepted: 01/25/2012] [Indexed: 11/25/2022]
Abstract
INTRODUCTION No information exists, to our knowledge, about the possible role of cardiovascular drug administration in the acute phase of ischemic stroke and possible effects on stroke outcome. The aim of our study was to evaluate the relationship between in-hospital treatment with cardiovascular drugs in patients with acute ischemic stroke and some outcome indicators. METHODS AND RESULTS 1096 subjects enrolled in the GIFA study, who had a main discharge diagnosis of ischemic stroke represent the final sample. Drugs considered for the analysis were the following: ACE-inhibitors (ACEI), angiotensin II receptor blockers (ARBs), statins, calcium-channel-blockers (CCBs), antiplatelet (APL) drugs, antivitamin-k (VKAs), and heparins. As outcome indicators we choose in-hospital mortality, cognitive function evaluated by Hodkinson Abbreviated Mental Test (HAMT), and functional status evaluated by activity daily living (ADL). Indicators of a good outcome were: no in-hospital mortality, HAMT >6 and 0 ADL impaired. Patients with a good outcome showed a higher rate of in-hospital treatment with ACE-inhibitors, calcium-channel blockers and a lower rate of pre-treatment with heparin. CONCLUSIONS Our study suggests that if a patient with acute ischemic stroke has higher SBP at admission, higher total cholesterol plasma levels, a lower Charlson index and is treated with ACE-inhibitors, calcium channel blockers and antiplatelet drugs, the short term outcome is better in terms of in-hospital mortality and functional indicators such as cognitive and functional performance at discharge.
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Affiliation(s)
- A Tuttolomondo
- Dipartimento Biomedico di Medicina Interna e Specialistica, Università degli Studi di Palermo, P.zza delle Cliniche, n.2, 90127 Palermo, Italy.
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