Blood Pressure Management in Stroke

Design and validation of dual-point time-differentiated photoplethysmogram (2PPG) wearable for cuffless blood pressure estimation

BACKGROUND & OBJECTIVES

Measurement of blood pressure (BP) in ambulatory patients is crucial for at high-risk cardiovascular patients. A non-obtrusive, non-occluding device that continuously measures BP via photoplethysmography will enable long-term ambulatory assessment of BP. The aim of this study is to validate the metasense 2PPG cuffless wearable design for continuous BP estimation without ECG.

METHODS

A customized high-speed electronic optical sensor architecture with laterally spaced reflectance pulse oximetry was designed into a simple unobtrusive low-power wearable in the form of a watch. 78 volunteers with a mean age of 32.72 ± 7.4 years (21 to 64), 51% male, 49% female were recruited with ECG-2PPG signals acquired. The fiducial features of the 2PPG morphologies were then attributed to the estimator. A 9-1 K-fold cross-validation was applied in the ML.

RESULTS

The correlation for PTT-SBP was 0.971 and for PTT-DBP was 0.954. The mean absolute error was 3.167±1.636 mmHg for SBP and 6.4 ± 3.9 mm Hg for DBP. The ambulatory estimate for SBP and DBP for an individual over 3 days with 8-hour recordings was 0.70-0.81 for SBP and 0.42-0.51 for DBP with a ± 2.65 mmHg for SBP and ±2.02 mmHg for DBP. For SBP, 98% of metasense measurements were within 15 mm Hg and for DBP, 91% of metasense measurements were within 10 mmHg CONCLUSIONS: The metasense device provides continuous, non-invasive BP estimations that are comparable to ambulatory BP meters. The portability and unobtrusiveness of this device, as well as the ability to continuously measure BP could one day enable long-term ambulatory BP measurement for precision cardiovascular therapeutic regimens.

Hypertension, Neurodegeneration, and Cognitive Decline

Elevated blood pressure is a well-established risk factor for age-related cognitive decline. Long linked to cognitive impairment on vascular bases, increasing evidence suggests a potential association of hypertension with the neurodegenerative pathology underlying Alzheimer disease. Hypertension is well known to disrupt the structural and functional integrity of the cerebral vasculature. However, the mechanisms by which these alterations lead to brain damage, enhance Alzheimer pathology, and promote cognitive impairment remain to be established. Furthermore, critical questions concerning whether lowering blood pressure by antihypertensive medications prevents cognitive impairment have not been answered. Recent developments in neurovascular biology, brain imaging, and epidemiology, as well as new clinical trials, have provided insights into these critical issues. In particular, clinical and basic findings on the link between neurovascular dysfunction and the pathobiology of neurodegeneration have shed new light on the overlap between vascular and Alzheimer pathology. In this review, we will examine the progress made in the relationship between hypertension and cognitive impairment and, after a critical evaluation of the evidence, attempt to identify remaining knowledge gaps and future research directions that may advance our understanding of one of the leading health challenges of our time.

Association of hypertension burden with stroke risk in patients with heart failure with preserved ejection fraction

Introduction

Whether the hypertension burden is associated with stroke incidence is inconclusive. In this study, we aimed to investigate the relationship between hypertension burden and stroke risk in patients with heart failure with preserved ejection fraction (HFpEF).

Methods

HFpEF patients from the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial were divided into three groups (low, medium, and high risk) according to their hypertension burden values. Higher hypertension burden risk represented the longer duration of hypertension. We evaluated the association of hypertension burden with stroke risk using Fine and Gray's competing risk models.

Results

A total of 3431 HFpEF patients (mean age: 68.5 ± 9.58 years, 51.6% females) were enrolled. During a median follow-up of 3.3 years, per 10-point increase in hypertension burden was associated with any stroke (hazard ratio [HR] 1.15, 95% confidence interval [CI] 1.08-1.21), new-onset stroke (HR 1.14, 95% CI 1.07-1.21), and ischemic stroke (HR 1.10, 95% CI 1.02-1.17). When hypertension burden was analyzed as a categorical variable, any stroke risk was increased in the medium- (HR 1.59, 95% CI 1.01-2.40) and high-risk (HR 3.19, 95% CI 2.05-4.97) groups when compared with the low-risk group. For the outcomes of new-onset (HR 2.92, 95% CI 1.80-4.74) and ischemic stroke (HR 2.46, 95% CI 1.41-4.29), similar results were observed in patients with high-versus low-risk hypertension burden.

Conclusions

Increasing hypertension burden was associated with an increased risk of stroke, suggesting that shortening hypertension duration might appropriately minimize the stroke incidence in HFpEF patients.

Exploring the efficacy of virtual reality-based rehabilitation in stroke: a narrative review of current evidence

BACKGROUND

Stroke rehabilitation presents a complex challenge, necessitating innovative approaches to optimise functional recovery. Virtual Reality-Based Rehabilitation (VRBR) has emerged as a promising intervention that capitalises on immersive technology to engage stroke survivors in their recovery journey. This review aims to examine the efficacy of VRBR in stroke rehabilitation, focusing on its advantages and challenges.

METHODS

A comprehensive search of relevant literature was conducted to gather evidence on the efficacy of VRBR in stroke survivors. Studies that investigated the impact of VRBR on patient engagement, functional recovery, and overall rehabilitation outcomes were included. The review also assessed the ability of VRBR to simulate real-life scenarios and facilitate essential daily activities for stroke survivors.

RESULTS

The review highlights that VRBR offers a unique immersive experience that enhances patient engagement and motivation during rehabilitation. The immersive nature of VRBR fosters a sense of presence, which can positively impact treatment adherence and outcomes. Moreover, VRBR's capacity to replicate real-world scenarios provides stroke survivors with opportunities to practice vital daily activities, promoting functional independence. In contrast, conventional rehabilitation methods lack the same level of engagement and real-world simulation.

CONCLUSION

VRBR holds promise as an efficacious intervention in stroke rehabilitation. Its immersive nature enhances patient engagement and motivation, potentially leading to better treatment adherence and outcomes. The ability of VRBR to simulate real-life scenarios offers a unique platform. However, challenges such as cost, equipment, patient suitability, data privacy, and acceptance must be addressed for successful integration into stroke rehabilitation practice.

Estimated Population Health Benefits of Intensive Systolic Blood Pressure Treatment Among SPRINT-Eligible US Adults

BACKGROUND

The Systolic Blood Pressure Intervention Trial (SPRINT) demonstrated an intensive (<120 mm Hg) vs. standard (<140 mm Hg) systolic blood pressure (SBP) goal lowered cardiovascular disease (CVD) risk. Estimating the effect of intensive SBP lowering among SPRINT-eligible adults most likely to benefit can guide implementation efforts.

METHODS

We studied SPRINT participants and SPRINT-eligible participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study and National Health and Nutrition Examination Surveys (NHANES). A published algorithm of predicted CVD benefit with intensive SBP treatment was used to categorize participants into low, medium, or high predicted benefit. CVD event rates were estimated with intensive and standard treatment.

RESULTS

Median age was 67.0, 72.0, and 64.0 years in SPRINT, SPRINT-eligible REGARDS, and SPRINT-eligible NHANES participants, respectively. The proportion with high predicted benefit was 33.0% in SPRINT, 39.0% in SPRINT-eligible REGARDS, and 23.5% in SPRINT-eligible NHANES. The estimated difference in CVD event rate (standard minus intensive) was 7.0 (95% confidence interval [CI] 3.4-10.7), 8.4 (95% CI 8.2-8.5), and 6.1 (95% CI 5.9-6.3) per 1,000 person-years in SPRINT, SPRINT-eligible REGARDS participants, and SPRINT-eligible NHANES participants, respectively (median 3.2-year follow-up). Intensive SBP treatment could prevent 84,300 (95% CI 80,800-87,920) CVD events per year in 14.1 million SPRINT-eligible US adults; 29,400 and 28,600 would be in 7.0 million individuals with medium or high predicted benefit, respectively.

CONCLUSIONS

Most of the population health benefit from intensive SBP goals could be achieved by treating those characterized by a previously published algorithm as having medium or high predicted benefit.

The Role of Vascular Risk Factors in Cognitive Impairment and Dementia and Prospects for Prevention

One of the most challenging clinical expressions of population aging is cognitive impairment and dementia. Among risk factors for the development of dementia, modifiable vascular risk factors have emerged as contributors to both vascular and nonvascular types of dementia. Epidemiologic studies have been particularly informative in understanding the link between vascular risks and dementia across the life course. We discuss vascular risks for dementia and cognitive impairment and practical management recommendations.

Potential nanotherapeutic strategies for perioperative stroke

AIMS

Based on the complex pathological environment of perioperative stroke, the development of targeted therapeutic strategies is important to control the development of perioperative stroke.

DISCUSSIONS

Recently, great progress has been made in nanotechnology, and nanodrug delivery systems have been developed for the treatment of ischemic stroke.

CONCLUSION

In this review, the pathological processes and mechanisms of ischemic stroke during perioperative stroke onset were systematically sorted. As a potential treatment strategy for perioperative stroke, the review also summarizes the multifunctional nanodelivery systems based on ischemic stroke, thus providing insight into the nanotherapeutic strategies for perioperative stroke.

Association Between Regular Blood Pressure Monitoring and the Risk of Intracranial Aneurysm Rupture: a Multicenter Retrospective Study with Propensity Score Matching

Although hypertension is a known risk factor for intracranial aneurysm rupture, the benefit of the management of blood pressure in reducing the rupture risk of intracranial aneurysms remains largely unknown, especially for regular blood pressure monitoring. We conducted a retrospective analysis of a prospectively maintained database of 3965 patients with saccular intracranial aneurysms from 20 medical centers in China. The patients were divided into the non-hypertensive group and hypertensive group. Propensity score matching was applied to identify a cohort of patients with similar baseline characteristics. Univariable and multivariable logistic regression analyses were performed to determine the association between intracranial aneurysm rupture and the management of blood pressure. After matching, hypertension was significantly associated with an increased rupture risk of intracranial aneurysms (OR = 2.559, 95%CI = 2.161-3.030, P = 0.000). For the management of blood pressure, controlled hypertension (OR = 1.803, 95%CI = 1.409-2.307, P = 0.000), uncontrolled hypertension (OR = 2.178, 95%CI = 1.756-2.700, P = 0.000), and hypertension without regular blood pressure monitoring (OR = 5.000, 95%CI = 3.823-6.540, P = 0.000) were all significantly associated with a higher rupture risk compared with the absence of hypertension. Moreover, hypertension without regular blood pressure monitoring was associated with a higher rupture risk compared with either controlled hypertension (OR = 3.807, 95%CI = 2.687-5.395, P = 0.000) or hypertension with regular blood pressure monitoring (including controlled and uncontrolled hypertension) (OR = 2.893, 95%CI = 2.319-3.609, P = 0.000). The absence of regular blood pressure monitoring was significantly associated with an increased risk of intracranial aneurysm rupture, emphasizing the importance of implementation of regular blood pressure monitoring in hypertensive patients with intracranial aneurysms.

Community Engagement: Lessons Learned From the AAASPS and SDBA

Community engagement is a means to help overcome challenges to the delivery of health care and preventative services. On the occasion of the 2021 International Stroke Conference Edgar J. Kenton III Lecture, I review community engagement strategies utilized in the AAASPS trial (African-American Antiplatelet Stroke Prevention Study) and SDBA (Studies of Dementia in the Black Aged) observational studies that I directed. The main community engagement strategies included use of home visits (bringing the study to the community), engagement of churches, community advisors, community physicians, other healthcare providers, major Black community organizations, and utilization of diversity training. Community engagement strategies were a major component of AAASPS and SDBA that helped to ensure successful recruitment and retention of an underrepresented community in clinical trial and observational studies. Lessons learned from these studies largely carried out in the 1980s and 1990s helped to dispel myths that Blacks could not be recruited into large-scale clinical trials, emphasized the importance of studying underrepresented groups with adequate statistical power to test primary study hypotheses, and provided foundational recruitment and retention methods for future consideration.

Incident Stroke and Its Influencing Factors in Patients With Type 2 Diabetes Mellitus and/or Hypertension: A Prospective Cohort Study

Objective

To understand the incidence of stroke in patients with type 2 diabetes mellitus (T2DM) and/or hypertension (HTN), and provide a basis for the prevention of stroke in these patients.

Methods

A prospective cohort study was performed for adults with T2DM and/or HTN. The follow-up period was 1 year. The incidence and recurrence rate of stroke was calculated and a multivariate Cox proportional hazard was used to analyze influencing factors of stroke occurrence and recurrence in the follow-up of patients with T2DM and/or HTN.

Results

Of the 1,650 patients with T2DM and/or HTN, 1,213 patients had no history of stroke. After 1 year of follow-up, 147 new stroke cases occurred, and the incidence rate of stroke was 12.1%. Among the patients who had stroke history (413), there were 116 cases of stroke with a recurrence rate of 26.5%. Seven risk factors were independently associated with stroke occurrence among patients without stroke history, included smoking, abnormal total cholesterol abnormal low-density lipoprotein patients with comorbid T2DM with HTN, physical inactivity, carotid artery stenosis (CAS), and higher scores of National Institutes of Health Stroke Scale (NIHSS). Higher scores of NHISS and CAS were independent risk factors for the recurrence of stroke among patients with stroke history.

Conclusions

Patients with T2DM and/or HTN have a higher rate of new stroke and recurrence after 1-year follow-up. Actively identifying the controllable risk factors, such as smoking and physical inactivity, will help reduce the risk of stroke and recurrence in patients with T2DM and HTN.

New findings bearing on the prevention, detection and management of high blood pressure

PURPOSE OF REVIEW

Hypertension is the foremost risk factor for cardiovascular disease (CVD) and death. This review highlights recent findings that apply to the prevention, detection, and management of high blood pressure (BP), in the context of the 2017 American College of Cardiology/American Heart Association BP guideline.

RECENT FINDINGS

Several new findings on the association of BP measurement with CVD outcomes are now available. (1) Beginning with a systolic BP (SBP) as low as 90 mm Hg, coronary artery calcium deposition and the risk of incident atherosclerotic CVD (ASCVD) increased in stepwise fashion with increasing SBP levels within the normal range in adults at low risk for ASCVD. (2) Isolated diastolic hypertension was not associated with ASCVD, heart failure, or chronic kidney disease. (3) Nocturnal BP appeared to be better associated with CVD outcomes than office or daytime BP. (4) In a head-to-head comparison, home BP monitoring had higher reliability and predictive value than office or ambulatory BP to detect left ventricular hypertrophy, an intermediate form of hypertension-related target organ damage. In addition, new information indicates that autonomous aldosterone production is present in a substantially larger percentage of adults with hypertension than previously recognized. Finally, intensive BP lowering is associated with a significant reduction in the incidence of mild cognitive impairment, a precursor of dementia.

SUMMARY

Ongoing research has made significant progress in the prevention, detection, and management of high BP, clarifying, amplifying, and/or supporting the 2017 ACC/AHA BP guideline recommendations.

Guideline-Driven Management of Hypertension: An Evidence-Based Update

Several important findings bearing on the prevention, detection, and management of hypertension have been reported since publication of the 2017 American College of Cardiology/American Heart Association Blood Pressure Guideline. This review summarizes and places in context the results of relevant observational studies, randomized clinical trials, and meta-analyses published between January 2018 and March 2021. Topics covered include blood pressure measurement, patient evaluation for secondary hypertension, cardiovascular disease risk assessment and blood pressure threshold for drug therapy, lifestyle and pharmacological management, treatment target blood pressure goal, management of hypertension in older adults, diabetes, chronic kidney disease, resistant hypertension, and optimization of care using patient, provider, and health system approaches. Presenting new information in each of these areas has the potential to increase hypertension awareness, treatment, and control which remain essential for the prevention of cardiovascular disease and mortality in the future.

MRI tracking/detection of bone marrow mesenchymal stromal cells transplantation for treatment of ischemic cerebral infarction

Background

Cerebral stroke is the second leading cause of death with high mortality and morbidity worldwide, currently it lacks effective therapies to improve the prognosis. This study was aimed to explore the role of bone marrow mesenchymal stem cells (BMSCs) transplantation in the recovery of brain structure and function after ischemic cerebral infarction by magnetic resonance imaging (MRI).

Methods

By applying internal carotid artery embolization, the ischemic cerebral infarction model in rats was established. MRI was performed to detect the imaging changes in the brain tissue after modeling, and the successful modeling was evidenced by the presence of obvious high-signal infarct areas in the brain. BMSCs were then injected into the lateral ventricles of rats, and the recovery of brain tissue and function were quantitatively evaluated by T2-weighted image (T2WI) and voxel-based morphology (VBM) after 28 days.

Results

The results showed that BMSCs were cell subsets with multiple differentiation potentials. Deficits caused by Ischemic cerebral infarction were relieved by BMSCs transplantation, including increase in damaged cerebral tissue and recovery of cerebral function. In addition, the combined imaging technology of VBM and T2WI quantitatively revealed the effectiveness of BMSCs in repairing damaged brain tissue structure and function.

Conclusion

Taken together, the results revealed that the transplantation of BMSCs into the lateral ventricle was beneficial to repair the structure and function of the damaged brain tissue after ischemic cerebral infarction. Moreover, the combination of VBM and T2WI technology can detect the level of brain injury in ischemic cerebral infarction dynamically and noninvasively, and evaluate the recovery of structure and function of damaged brain tissue.