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Miller JB, Hrabec D, Krishnamoorthy V, Kinni H, Brook RD. Evaluation and management of hypertensive emergency. BMJ 2024; 386:e077205. [PMID: 39059997 DOI: 10.1136/bmj-2023-077205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2024]
Abstract
Hypertensive emergencies cause substantial morbidity and mortality, particularly when acute organ injury is present. Careful and effective strategies to reduce blood pressure and diminish the effects of pressure-mediated injury are essential. While the selection of specific antihypertensive medications varies little across different forms of hypertensive emergencies, the intensity of blood pressure reduction to the target pressure differs substantially. Treatment hinges on balancing the positive effects of lowering blood pressure with the potential for negative effects of organ hypoperfusion in patients with altered autoregulatory mechanisms. When patients do not have acute organ injury in addition to severe hypertension, they benefit from a conservative, outpatient approach to blood pressure management. In all cases, long term control of blood pressure is paramount to prevent recurrent hypertensive emergencies and improve overall prognosis. This review discusses the current evidence and guidelines on the evaluation and management of hypertensive emergency.
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Affiliation(s)
- Joseph B Miller
- Department of Emergency Medicine, Division of Critical Care Medicine, Henry Ford Health and Michigan State University Health Sciences, Detroit, MI, USA
| | - Daniel Hrabec
- Department of Emergency Medicine, Division of Critical Care Medicine, Henry Ford Health and Michigan State University Health Sciences, Detroit, MI, USA
| | - Vijay Krishnamoorthy
- Department of Anesthesiology, Division of Critical Care Medicine, Duke University, Durham, NC, USA
| | - Harish Kinni
- Department of Emergency Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Mayo Clinic, Rochester, MN, USA
| | - Robert D Brook
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wayne State University, Detroit, MI, USA
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Dong R, Li F, Li B, Chen Q, Huang X, Zhang J, Huang Q, Zhang Z, Cao Y, Yang M, Li J, Li Z, Li C, Liu G, Zhong S, Feng G, Zhang M, Xiao Y, Lin K, Shen Y, Shao H, Shi Y, Yu X, Li X, Yao L, Du X, Xu Y, Kang P, Gao G, Ouyang B, Chen W, Zeng Z, Chen P, Chen C, Yang H. Effects of an Early Intensive Blood Pressure-lowering Strategy Using Remifentanil and Dexmedetomidine in Patients with Spontaneous Intracerebral Hemorrhage: A Multicenter, Prospective, Superiority, Randomized Controlled Trial. Anesthesiology 2024; 141:100-115. [PMID: 38537025 DOI: 10.1097/aln.0000000000004986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2024]
Abstract
BACKGROUND Although it has been established that elevated blood pressure and its variability worsen outcomes in spontaneous intracerebral hemorrhage, antihypertensives use during the acute phase still lacks robust evidence. A blood pressure-lowering regimen using remifentanil and dexmedetomidine might be a reasonable therapeutic option given their analgesic and antisympathetic effects. The objective of this superiority trial was to validate the efficacy and safety of this blood pressure-lowering strategy that uses remifentanil and dexmedetomidine in patients with acute intracerebral hemorrhage. METHODS In this multicenter, prospective, single-blinded, superiority randomized controlled trial, patients with intracerebral hemorrhage and systolic blood pressure (SBP) 150 mmHg or greater were randomly allocated to the intervention group (a preset protocol with a standard guideline management using remifentanil and dexmedetomidine) or the control group (standard guideline-based management) to receive blood pressure-lowering treatment. The primary outcome was the SBP control rate (less than 140 mmHg) at 1 h posttreatment initiation. Secondary outcomes included blood pressure variability, neurologic function, and clinical outcomes. RESULTS A total of 338 patients were allocated to the intervention (n = 167) or control group (n = 171). The SBP control rate at 1 h posttreatment initiation in the intervention group was higher than that in controls (101 of 161, 62.7% vs. 66 of 166, 39.8%; difference, 23.2%; 95% CI, 12.4 to 34.1%; P < 0.001). Analysis of secondary outcomes indicated that patients in the intervention group could effectively reduce agitation while achieving lighter sedation, but no improvement in clinical outcomes was observed. Regarding safety, the incidence of bradycardia and respiratory depression was higher in the intervention group. CONCLUSIONS Among intracerebral hemorrhage patients with a SBP 150 mmHg or greater, a preset protocol using a remifentanil and dexmedetomidine-based standard guideline management significantly increased the SBP control rate at 1 h posttreatment compared with the standard guideline-based management. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Rui Dong
- Department of Critical Care Medicine, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Fen Li
- Department of Critical Care Medicine, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Bin Li
- Department of Intensive Care Unit, The First Hospital of Lanzhou University, Lanzhou, China
| | - Qiming Chen
- Department of Intensive Care Unit, The First Hospital of Lanzhou University, Lanzhou, China
| | - Xianjian Huang
- Department of Neurosurgery, Shenzhen Key Laboratory of Neurosurgery, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, China
| | - Jiehua Zhang
- Department of Neurosurgery, Shenzhen Key Laboratory of Neurosurgery, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, China
| | - Qibing Huang
- Department of Emergency Neurosurgical Intensive Care Unit, Qilu Hospital of Shandong University and Brain Science Research Institute of Shandong University, Jinan, China
| | - Zeli Zhang
- Department of Emergency Neurosurgical Intensive Care Unit, Qilu Hospital of Shandong University and Brain Science Research Institute of Shandong University, Jinan, China
| | - Yunxing Cao
- Department of Intensive Care Unit, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Mingbiao Yang
- Neurosurgery Department, The First Affiliated Hospital of Hunan University of Medicine, Huaihua, China
| | - Jianwei Li
- Department of Critical Care Medicine, Zhongshan People's Hospital, Zhongshan, China
| | - Zhanfu Li
- Department of Intensive Care Unit, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Cuiyu Li
- Department of Intensive Care Unit, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Guohua Liu
- Department of Neurosurgery, The Fifth Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Shu Zhong
- Department of Neurosurgery, Guangxi Hospital Division of the First Affiliated Hospital, Sun Yat-sen University, Nanning, China
| | - Guang Feng
- Department of Neurosurgery, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Ming Zhang
- Department of Neurosurgery, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Yumei Xiao
- Neurological Intensive Medicine Department, Maoming People's Hospital, Maoming, China
| | - Kangyue Lin
- Neurological Intensive Medicine Department, Maoming People's Hospital, Maoming, China
| | - Yunlong Shen
- Department of Neurosurgery, The Fifth Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Huanzhang Shao
- Department of Critical Care Medicine, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuan Shi
- Department of Critical Care Medicine, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiangyou Yu
- Department of Critical Care Medicine, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Xiaopeng Li
- Department of Critical Care Medicine, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Lan Yao
- Department of Emergency Medicine, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Xinyu Du
- Department of Emergency Medicine, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Ying Xu
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China
| | - Pei Kang
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China
| | - Guoyi Gao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bin Ouyang
- Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Wenjin Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zhenhua Zeng
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Pingyan Chen
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China
| | - Chunbo Chen
- Department of Critical Care Medicine, Shenzhen People's Hospital, The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen, China
| | - Hong Yang
- Department of Critical Care Medicine, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
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Han X, Luo G, Li J, Liu R, Zhu N, Jiang S, Ma W, Cheng Y, Liu F. Association between blood pressure control during aneurysm clipping and functional outcomes in patients with aneurysmal subarachnoid hemorrhage. Front Neurol 2024; 15:1415840. [PMID: 38859973 PMCID: PMC11163112 DOI: 10.3389/fneur.2024.1415840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 05/14/2024] [Indexed: 06/12/2024] Open
Abstract
Objectives We explored the relationship between blood pressure variability (BPV) during craniotomy aneurysm clipping and short-term prognosis in patients with aneurysmal subarachnoid hemorrhage to provide a new method to improve prognosis of these patients. Methods We retrospectively analyzed the differences between patient groups with favorable modified Rankin Scale (mRS ≤ 2) and unfavorable (mRS > 2) prognosis, and examined the association between intraoperative BPV and short-term prognosis. Results The intraoperative maximum systolic blood pressure (SBPmax, p = 0.005) and the coefficient of variation of diastolic blood pressure (DBPCV, p = 0.029) were significantly higher in the favorable prognosis group. SBPmax (OR 0.88, 95%CI 0.80-0.98) and Neu% (OR 1.22, 95%CI 1.03-1.46) were independent influence factors on prognosis. Patients with higher standard deviations of SBP (82.7% vs. 56.7%; p = 0.030), DBP (82.7% vs. 56.7%; p = 0.030), and DBPCV (82.7% vs. 56.7%; p = 0.030) had more favorable prognosis. Conclusion Higher SBPmax (≤180 mmHg) during the clipping is an independent protective factor for a 90-day prognosis. These results highlight the importance of blood pressure (BP) control for improved prognosis; higher short-term BPV during clipping may be a precondition for a favorable prognosis.
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Affiliation(s)
| | | | | | | | | | | | | | - Yawen Cheng
- Department of Neurology and Stroke Center, The First Affiliated Hospital of Xi'an Jiaotong University, Xi’an, Shaanxi, China
| | - Fude Liu
- Department of Neurology and Stroke Center, The First Affiliated Hospital of Xi'an Jiaotong University, Xi’an, Shaanxi, China
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Qureshi AI, Baskett WI, Lodhi A, Gomez F, Arora N, Chandrasekaran PN, Siddiq F, Gomez CR, Shyu CR. Assessment of Blood Pressure and Heart Rate Related Variables in Acute Stroke Patients Receiving Intravenous Antihypertensive Medication Infusions. Neurocrit Care 2024:10.1007/s12028-024-01974-8. [PMID: 38649651 DOI: 10.1007/s12028-024-01974-8] [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: 06/20/2023] [Accepted: 03/07/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND We performed an analysis of a large intensive care unit electronic database to provide preliminary estimates of various blood pressure parameters in patients with acute stroke receiving intravenous (IV) antihypertensive medication and determine the relationship with in-hospital outcomes. METHODS We identified the relationship between pre-treatment and post-treatment systolic blood pressure (SBP) and heart rate (HR)-related variables and in-hospital mortality and acute kidney injury in patients with acute stroke receiving IV clevidipine, nicardipine, or nitroprusside using data provided in the Medical Information Mart for Intensive Care (MIMIC) IV database. RESULTS A total of 1830 patients were treated with IV clevidipine (n = 64), nicardipine (n = 1623), or nitroprusside (n = 143). The standard deviations [SDs] of pre-treatment SBP (16.3 vs. 13.7, p ≤ 0.001) and post-treatment SBP (15.4 vs. 14.4, p = 0.004) were higher in patients who died compared with those who survived, particularly in patients with intracerebral hemorrhage (ICH). The mean SBP was significantly lower post treatment compared with pre-treatment values for clevidipine (130.7 mm Hg vs. 142.5 mm Hg, p = 0.006), nicardipine (132.8 mm Hg vs. 141.6 mm Hg, p ≤ 0.001), and nitroprusside (126.2 mm Hg vs. 139.6 mm Hg, p ≤ 0.001). There were no differences in mean SDs post treatment compared with pre-treatment values for clevidipine (14.5 vs. 13.5, p = 0.407), nicardipine (14.2 vs. 14.6, p = 0.142), and nitroprusside (14.8 vs. 14.8, p = 0.997). The SDs of pre-treatment and post-treatment SBP were not significantly different in patients with ischemic stroke treated with IV clevidipine, nicardipine, or nitroprusside or for patients with ICH treated with IV clevidipine or nitroprusside. However, patients with ICH treated with IV nicardipine had a significantly higher SD of post-treatment SBP (13.1 vs. 14.2, p = 0.0032). CONCLUSIONS We found that SBP fluctuations were associated with in-hospital mortality in patients with acute stroke. IV antihypertensive medication reduced SBP but did not reduce SBP fluctuations in this observational study. Our results highlight the need for optimizing therapeutic interventions to reduce SBP fluctuations in patients with acute stroke.
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Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Institute, ZQSI, St. Cloud, MN, USA.
- Department of Neurology, University of Missouri, Columbia, MO, USA.
| | - William I Baskett
- Institute for Data Science and Informatics, University of Missouri, Columbia, MO, USA
| | - Abdullah Lodhi
- Zeenat Qureshi Stroke Institute, ZQSI, St. Cloud, MN, USA
| | - Francisco Gomez
- Department of Neurology, University of Missouri, Columbia, MO, USA
| | - Niraj Arora
- Department of Neurology, University of Missouri, Columbia, MO, USA
| | | | - Farhan Siddiq
- Division of Neurosurgery, University of Missouri, Columbia, MO, USA
| | - Camilo R Gomez
- Department of Neurology, University of Missouri, Columbia, MO, USA
| | - Chi-Ren Shyu
- Institute for Data Science and Informatics, University of Missouri, Columbia, MO, USA
- Department of Electrical Engineering and Computer Science, University of Missouri, Columbia, MO, USA
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Alshehri A, Ince J, Panerai RB, Divall P, Robinson TG, Minhas JS. Physiological Variability during Prehospital Stroke Care: Which Monitoring and Interventions Are Used? Healthcare (Basel) 2024; 12:835. [PMID: 38667597 PMCID: PMC11050416 DOI: 10.3390/healthcare12080835] [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: 02/13/2024] [Revised: 03/24/2024] [Accepted: 04/08/2024] [Indexed: 04/28/2024] Open
Abstract
Prehospital care is a fundamental component of stroke care that predominantly focuses on shortening the time between diagnosis and reaching definitive stroke management. With growing evidence of the physiological parameters affecting long-term patient outcomes, prehospital clinicians need to consider the balance between rapid transfer and increased physiological-parameter monitoring and intervention. This systematic review explores the existing literature on prehospital physiological monitoring and intervention to modify these parameters in stroke patients. The systematic review was registered on PROSPERO (CRD42022308991) and conducted across four databases with citation cascading. Based on the identified inclusion and exclusion criteria, 19 studies were retained for this review. The studies were classified into two themes: physiological-monitoring intervention and pharmacological-therapy intervention. A total of 14 included studies explored prehospital physiological monitoring. Elevated blood pressure was associated with increased hematoma volume in intracerebral hemorrhage and, in some reports, with increased rates of early neurological deterioration and prehospital neurological deterioration. A reduction in prehospital heart rate variability was associated with unfavorable clinical outcomes. Further, five of the included records investigated the delivery of pharmacological therapy in the prehospital environment for patients presenting with acute stroke. BP-lowering interventions were successfully demonstrated through three trials; however, evidence of their benefit to clinical outcomes is limited. Two studies investigating the use of oxygen and magnesium sulfate as neuroprotective agents did not demonstrate an improvement in patient's outcomes. This systematic review highlights the absence of continuous physiological parameter monitoring, investigates fundamental physiological parameters, and provides recommendations for future work, with the aim of improving stroke patient outcomes.
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Affiliation(s)
- Abdulaziz Alshehri
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHiASM) Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK; (A.A.); (R.B.P.); (T.G.R.)
- College of Applied Medical Sciences, University of Najran, Najran P.O. Box 1988, Saudi Arabia
| | - Jonathan Ince
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHiASM) Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK; (A.A.); (R.B.P.); (T.G.R.)
| | - Ronney B. Panerai
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHiASM) Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK; (A.A.); (R.B.P.); (T.G.R.)
- NIHR Leicester Biomedical Research Centre, British Heart Foundation Cardiovascular Research Centre, Glenfield Hospital, Leicester LE3 9QP, UK
| | - Pip Divall
- University Hospitals of Leicester NHS Trust, Leicester LE1 5WW, UK;
| | - Thompson G. Robinson
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHiASM) Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK; (A.A.); (R.B.P.); (T.G.R.)
- NIHR Leicester Biomedical Research Centre, British Heart Foundation Cardiovascular Research Centre, Glenfield Hospital, Leicester LE3 9QP, UK
| | - Jatinder S. Minhas
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHiASM) Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK; (A.A.); (R.B.P.); (T.G.R.)
- NIHR Leicester Biomedical Research Centre, British Heart Foundation Cardiovascular Research Centre, Glenfield Hospital, Leicester LE3 9QP, UK
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Zompola C, Palaiodimou L, Voumvourakis K, Stefanis L, Katsanos AH, Sandset EC, Boviatsis E, Tsivgoulis G. Blood Pressure Variability in Acute Stroke: A Narrative Review. J Clin Med 2024; 13:1981. [PMID: 38610746 PMCID: PMC11012361 DOI: 10.3390/jcm13071981] [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: 03/12/2024] [Revised: 03/25/2024] [Accepted: 03/27/2024] [Indexed: 04/14/2024] Open
Abstract
The management of blood pressure variability (BPV) in acute stroke presents a complex challenge with profound implications for patient outcomes. This narrative review examines the role of BPV across various stages of acute stroke care, highlighting its impact on treatment strategies and prognostic considerations. In the prehospital setting, while guidelines lack specific recommendations for BP management, emerging evidence suggests a potential link between BPV and outcomes. Among ischaemic stroke patients who are ineligible for reperfusion therapies, BPV independently influences functional outcomes, emphasising the need for individualised approaches to BP control. During intravenous thrombolysis and endovascular therapy, the intricate interplay between BP levels, recanalisation status, and BPV is evident. Striking a balance between aggressive BP lowering and avoiding hypoperfusion-related complications is essential. Intracerebral haemorrhage management is further complicated by BPV, which emerges as a predictor of mortality and disability, necessitating nuanced BP management strategies. Finally, among patients with acute subarachnoid haemorrhage, increased BPV may be correlated with a rebleeding risk and worse outcomes, emphasizing the need for BPV monitoring in this population. Integration of BPV assessment into clinical practice and research protocols is crucial for refining treatment strategies that are tailored to individual patient needs. Future studies should explore novel interventions targeting BPV modulation to optimise stroke care outcomes.
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Affiliation(s)
- Christina Zompola
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Lina Palaiodimou
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Konstantinos Voumvourakis
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Leonidas Stefanis
- First Department of Neurology, “Aeginition” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Aristeidis H. Katsanos
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, ON L8L2X2, Canada
| | - Else C. Sandset
- Stroke Unit, Department of Neurology, Oslo University Hospital, N-0424 Oslo, Norway
| | - Estathios Boviatsis
- Second Department of Neurosurgery, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
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Cardona S, Baqai H, Mikdashi F, Aligabi A, Solomon J, Frederick H, Seyoum N, Olexa J, Stokum JA, Sharma A, Pergakis MB, Tran QK. Intracranial and Blood Pressure Variability and In-Hospital Outcomes in Intracranial Device-Monitored Patients with Spontaneous Intracerebral Hemorrhage. Neurocrit Care 2023; 39:357-367. [PMID: 36759420 DOI: 10.1007/s12028-023-01677-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 01/09/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Spontaneous intracerebral hemorrhage (sICH) is a major health concern and has high mortality rates up to 52%. Despite a decrease in its incidence, fatality rates remain unchanged; understanding and preventing of factors associated with mortality and treatments for these are needed. Blood pressure variability (BPV) has been shown to be a potential modifiable factor associated with clinical outcomes in patients with traumatic intracerebral hemorrhage and sICH. Few data are available on the effect of intracranial pressure (ICP) variability (ICPV) and outcomes in patients with sICH. The goal of our study was to investigate the association between ICPV and BPV during the first 24 h of intensive care unit (ICU) admission and external ventricular drain (EVD) placement, and mortality in patients with sICH who were monitored with an EVD. METHODS We conducted a single-center retrospective study of adult patients admitted to an ICU with a diagnosis of sICH who required EVD placement during hospitalization. We excluded patients with ICH secondary to other pathological conditions such as trauma, underlying malignancy, or arteriovenous malformation. Blood pressure and ICP measurements were collected and recorded hourly during the first 24 h of ICU admission and EVD placement, respectively. Measures of variability used were standard deviation (SD) and successive variation (SV). Primary outcome of interest was in-hospital mortality, and secondary outcomes were hematoma expansion and discharge home (a surrogate for good functional outcome at discharge). Descriptive statistics and multivariable logistic regressions were performed. RESULTS We identified 179 patients with sICH who required EVD placement. Of these, 52 (29%) patients died, 121 (68%) patients had hematoma expansion, and 12 (7%) patients were discharged home. Patient's mean age (± SD) was 56 (± 14), and 87 (49%) were women. The mean opening ICP (± SD) was 21 (± 8) and median ICH score (interquartile range) was 2 (2-3). Multivariable logistic regression found an association between ICP-SV and ICP-SD and hematoma expansion (odds ratio 1.6 [1.03-2.30], p = 0.035 and odds ratio 0.77 [0.63-0.93] p = 0.009, respectively). CONCLUSIONS Our study found an association between ICPV and hematoma expansion in patients with sICH monitored with an EVD. Measures of ICPV relating to rapid changes in ICP (ICP-SV) were associated with a higher odds of hematoma expansion, whereas measures relating to tight control of ICP (ICP-SD) were associated with a lower odds of hematoma expansion. One measure of BPV, sytolic blood pressure maximum-minimum (SBP max-min), was found to be weakly associated with discharge home (a surrogate for good functional outcome at hospital discharge). More research is needed to support these findings.
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Affiliation(s)
- Stephanie Cardona
- Department of Critical Care Medicine, The Mount Sinai Hospital, 1468 Madison Ave, New York, NY, 10029, USA.
| | - Hammad Baqai
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Fatima Mikdashi
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ayah Aligabi
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Julianna Solomon
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Hannah Frederick
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nahom Seyoum
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Joshua Olexa
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jesse A Stokum
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ashish Sharma
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Melissa B Pergakis
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Quincy K Tran
- Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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8
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Yu Y, Gong Y, Hu B, Ouyang B, Pan A, Liu J, Liu F, Shang XL, Yang XH, Tu G, Wang C, Ma S, Fang W, Liu L, Liu J, Chen D. Expert consensus on blood pressure management in critically ill patients. JOURNAL OF INTENSIVE MEDICINE 2023; 3:185-203. [PMID: 37533806 PMCID: PMC10391579 DOI: 10.1016/j.jointm.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/02/2023] [Accepted: 06/08/2023] [Indexed: 08/04/2023]
Affiliation(s)
- Yuetian Yu
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200001, China
| | - Ye Gong
- Department of Critical Care Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Bo Hu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China
| | - Bin Ouyang
- Department of Critical Care Medicine, The First Affiliated Hospital of SunYatsen University, Guangzhou 510080, Guangdong, China
| | - Aijun Pan
- Department of Critical Care Medicine, The First Affiliated Hospital of USTC, Division of Life Science and Medicine, University of Science and Technology of China, Hefei 230001, Anhui, China
| | - Jinglun Liu
- Department of Emergency Medicine and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Fen Liu
- Department of Critical Care Medicine, The First Affiliated Hospital of Nanchang University, Nanchang 330000, Jiangxi, China
| | - Xiu-Ling Shang
- Department of Critical Care Medicine, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Center for Critical Care Medicine, Fujian Provincial Key Laboratory of Critical Care Medicine, Fuzhou 350001 Fujian, China
| | - Xiang-Hong Yang
- Department of Intensive Care Unit, Emergency & Intensive Care Unit Center, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou 310014 Zhejiang, China
| | - Guowei Tu
- Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Changsong Wang
- Department of Critical Care Medicine, the First Affiliated Hospital of Harbin Medical University, Harbin 150001, Heilongjiang, China
| | - Shaolin Ma
- Department of Critical Care Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Wei Fang
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Shandong First Medical University, Jinan, 250014 Shandong, China
| | - Ling Liu
- Department of Critical Care Medicine, Jiangsu Provincial Key Laboratory of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009 Jiangsu, China
| | - Jiao Liu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Dechang Chen
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
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Appleton JP, Law ZK, Woodhouse LJ, Al-Shahi Salman R, Beridze M, Christensen H, Dineen RA, Guerrero JJE, England TJ, Karlinski M, Krishnan K, Laska AC, Lyrer P, Ozturk S, Roffe C, Roberts I, Robinson TG, Scutt P, Werring DJ, Bath PM, Sprigg N. Effects of blood pressure and tranexamic acid in spontaneous intracerebral haemorrhage: a secondary analysis of a large randomised controlled trial. BMJ Neurol Open 2023; 5:e000423. [PMID: 37337529 PMCID: PMC10277112 DOI: 10.1136/bmjno-2023-000423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 03/06/2023] [Indexed: 06/21/2023] Open
Abstract
Background Tranexamic acid reduced haematoma expansion and early death, but did not improve functional outcome in the tranexamic acid for hyperacute spontaneous intracerebral haemorrhage-2 (TICH-2) trial. In a predefined subgroup, there was a statistically significant interaction between prerandomisation baseline systolic blood pressure (SBP) and the effect of tranexamic acid on functional outcome (p=0.019). Methods TICH-2 was an international prospective double-blind placebo-controlled randomised trial evaluating intravenous tranexamic acid in patients with acute spontaneous intracerebral haemorrhage (ICH). Prerandomisation baseline SBP was split into predefined ≤170 and >170 mm Hg groups. The primary outcome at day 90 was the modified Rankin Scale (mRS), a measure of dependency, analysed using ordinal logistic regression. Haematoma expansion was defined as an increase in haematoma volume of >33% or >6 mL from baseline to 24 hours. Data are OR or common OR (cOR) with 95% CIs, with significance at p<0.05. Results Of 2325 participants in TICH-2, 1152 had baseline SBP≤170 mm Hg and were older, had larger lobar haematomas and were randomised later than 1173 with baseline SBP>170 mm Hg. Tranexamic acid was associated with a favourable shift in mRS at day 90 in those with baseline SBP≤170 mm Hg (cOR 0.73, 95% CI 0.59 to 0.91, p=0.005), but not in those with baseline SBP>170 mm Hg (cOR 1.05, 95% CI 0.85 to 1.30, p=0.63). In those with baseline SBP≤170 mm Hg, tranexamic acid reduced haematoma expansion (OR 0.62, 95% CI 0.47 to 0.82, p=0.001), but not in those with baseline SBP>170 mm Hg (OR 1.02, 95% CI 0.77 to 1.35, p=0.90). Conclusions Tranexamic acid was associated with improved clinical and radiological outcomes in ICH patients with baseline SBP≤170 mm Hg. Further research is needed to establish whether certain subgroups may benefit from tranexamic acid in acute ICH. Trial registration number ISRCTN93732214.
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Affiliation(s)
- Jason Philip Appleton
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Zhe Kang Law
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
- Neurology Unit, Department of Medicine, National University of Malaysia Faculty of Medicine, Kuala Lumpur, Malaysia
| | - Lisa Jane Woodhouse
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | | | - Maia Beridze
- The First University Clinic, Tbilisi State Medical University, Tbilisi, Georgia
| | - Hanne Christensen
- Department of Neurology, Copenhagen University Hospital, Bispebjerg, Denmark
| | - Robert A Dineen
- Radiological Sciences, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Juan José Egea Guerrero
- Neurocritical Care Unit, Virgen del Rocio University Hospital, Sevilla, Spain
- IbiS, CSIC, University of Seville, Sevilla, Spain
| | - Timothy J England
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Michal Karlinski
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Kailash Krishnan
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Ann Charlotte Laska
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden
| | - Philippe Lyrer
- Neurology and Stroke Center, University Hospital Basel, Basel, Switzerland
| | - Serefnur Ozturk
- Neurology, Faculty of Medicine, Selcuk Universitesi, Konya, Turkey
| | - Christine Roffe
- Stroke Research, School of Medicine, University of Keele, Stoke-on-Trent, UK
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Polly Scutt
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - David J Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
| | - Philip M Bath
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Nikola Sprigg
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
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Sondag L, Wolsink A, Jolink WMT, Voigt S, van Walderveen MAA, Wermer MJH, Klijn CJM, Schreuder FHBM. The association between blood pressure variability and perihematomal edema after spontaneous intracerebral hemorrhage. Front Neurol 2023; 14:1114602. [PMID: 37006500 PMCID: PMC10060834 DOI: 10.3389/fneur.2023.1114602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 03/01/2023] [Indexed: 03/18/2023] Open
Abstract
BackgroundPerihematomal edema (PHE) after spontaneous intracerebral hemorrhage (sICH) is associated with clinical deterioration, but the etiology of PHE development is only partly understood.AimsWe aimed to investigate the association between systemic blood pressure (BP) variability (BPV) and formation of PHE.MethodsFrom a multicenter prospective observational study, we selected patients with sICH who underwent 3T brain MRI within 21 days after sICH, and had at least 5 BP measurements available in the first week after sICH. Primary outcome was the association between coefficient of variation (CV) of systolic BP (SBP) and edema extension distance (EED) using multivariable linear regression, adjusting for age, sex, ICH volume and timing of the MRI. In addition, we investigated the associations of mean SBP, mean arterial pressure (MAP), their CVs with EED and absolute and relative PHE volume.ResultsWe included 92 patients (mean age 64 years; 74% men; median ICH volume 16.8 mL (IQR 6.6–36.0), median PHE volume 22.5 mL (IQR 10.2–41.4). Median time between symptom onset and MRI was 6 days (IQR 4–11), median number of BP measurements was 25 (IQR 18–30). Log-transformed CV of SBP was not associated with EED (B = 0.050, 95%-CI −0.186 to 0.286, p = 0.673). Furthermore, we found no association between mean SBP, mean and CV of MAP and EED, nor between mean SBP, mean MAP or their CVs and absolute or relative PHE.DiscussionOur results do not support a contributing role for BPV on PHE, suggesting mechanisms other than hydrostatic pressure such as inflammatory processes, may play a more important role.
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Affiliation(s)
- Lotte Sondag
- Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
| | - Axel Wolsink
- Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Sabine Voigt
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | | | | | - Catharina J. M. Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
| | - Floris H. B. M. Schreuder
- Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
- *Correspondence: Floris H. B. M. Schreuder
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Konar S, Florez-Perdomo W, Garcia-Ballestas E, Quiñones-Ossa GA, Janjua T, Moscote-Salazar LR, Mishra RK, Agrawal A. Blood pressure variability and prognosis in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. J Neurosurg Sci 2023; 67:10-17. [PMID: 34647715 DOI: 10.23736/s0390-5616.21.05477-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The subarachnoid hemorrhage due to a ruptured brain aneurysm is a neurological emergency with high mobility and mortality. Hypertensive states are related to a bad prognosis and a higher risk of a ruptured aneurysm. However, the relationship between the blood pressure variability with the aneurysmal subarachnoid hemorrhage and its prognosis is quite unknown. EVIDENCE ACQUISITION A systematic review was performed across the databases. The following descriptors and related were used for the search: blood pressure, arterial pressure, variability, subarachnoid hemorrhage, hemorrhage, aneurysmal, aneurysmal subarachnoid hemorrhage. The following data were extracted: Glasgow Outcome Scale or Modified Rankin Scale, and blood pressure variabilities to categorize the prognosis. EVIDENCE SYNTHESIS Five studies were selected. The blood pressure variability and the related outcome were assessed by mean systolic blood pressure and minimum systolic blood. The meta-analysis of mean systolic blood pressure (cut-off >95.3 mmHg) showed an odds ratio of 11.23 (95% CI: 4.423 to 28.537) (P≤0.001), predicting the good outcome after the aneurysmal subarachnoid hemorrhage. The pooled analysis revealed AUC of the ROC predicting the good outcome was statistically significant (AUC: 0.85, P<0.001). The pooled data analysis of minimum systolic blood pressure revealed an odds ratio of 6.43 (95% CI: 2.834-14.589, P<0.001) and AUC of the pooled ROC 0.931 (95% CI: 0.851 to 1.000, P<0.001) to predict poor outcome. The funnel plot through Egger's test for the analysis showed different grades of asymmetry. CONCLUSIONS The blood pressure variability (mean and minimum systolic blood pressure) is a good predictor and parameter in the aneurysmal subarachnoid hemorrhage prognosis and outcome prediction.
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Affiliation(s)
- Subhas Konar
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - William Florez-Perdomo
- Consejo Latinoamericano de Cuidado Neurocrítico (CLaNi), Cartagena, Colombia.,Centro De Investigaciones Biomédicas (CIB), Faculty of Medicine, University of Cartagena, Cartagena, Colombia
| | - Ezequiel Garcia-Ballestas
- Consejo Latinoamericano de Cuidado Neurocrítico (CLaNi), Cartagena, Colombia.,Centro De Investigaciones Biomédicas (CIB), Faculty of Medicine, University of Cartagena, Cartagena, Colombia
| | - Gabriel A Quiñones-Ossa
- Consejo Latinoamericano de Cuidado Neurocrítico (CLaNi), Cartagena, Colombia - .,Faculty of Medicine, El Bosque University, Bogotá, Colombia
| | | | - Luis R Moscote-Salazar
- Consejo Latinoamericano de Cuidado Neurocrítico (CLaNi), Cartagena, Colombia.,Centro De Investigaciones Biomédicas (CIB), Faculty of Medicine, University of Cartagena, Cartagena, Colombia
| | - Rakesh K Mishra
- Department of Neurosurgery, All India Institute of Medical Sciences, Saket Nagar, Bhopal, India
| | - Amit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, Saket Nagar, Bhopal, India
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Sun X, Jv X, Mi Q, Yang Q, Chen T, Jiang G. The effect of blood pressure variability on the prognosis of patients with acute cerebral hemorrhage: Possible mechanism. Front Neurosci 2022; 16:1035061. [PMID: 36545538 PMCID: PMC9762155 DOI: 10.3389/fnins.2022.1035061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 11/07/2022] [Indexed: 12/12/2022] Open
Abstract
Background Antihypertensive therapy in the acute phase of intracerebral hemorrhage (ICH) can reduce hematoma expansion. Numerous studies have demonstrated that blood pressure variability secondary to antihypertensive therapy has adverse effects on neurological outcomes, but the conclusions are diverse, and the mechanism of this occurrence is unknown. The aim of this research was to analyze the impact of blood pressure variability after antihypertensive treatment on the prognosis of patients with acute ICH, along with the possible mechanism. Materials and methods A total of 120 patients within 20 h of onset of ICH were divided into a good prognosis group (mRS ≤ 2 points) and a poor prognosis group (mRS ≥ 3 points) according to their 90-day mRS scores. The basic patient information, NIHSS score, GCS score, mRS score at 90 days after admission, head CT examination at admission and 24 h and CTP examination at 24 h were collected from some patients. The blood pressure values of patients were collected within 24 h, and multiple blood pressure variation (BPV) parameters within 1 and 24 h were calculated. Results (1) After excluding confounding factors such as age, whether the hematoma ruptured into the ventricle, confounding signs, amount of bleeding, edema around the hematoma, NIHSS on admission, operation or non-operation, and 24-h hematoma increment, the fourth quartile systolic blood pressure (SBP) maximum and minimum difference within 1 h [OR: 5.069, CI (1.036-24.813) P = 0.045] and coefficient of continuous variation (SV) within 24 h [OR: 2.912 CI (1.818-71.728) P = 0.009] were still independent factors affecting the 90-day mRS in ICH patients. (2) There was a negative correlation between SBP SV and CBF in terms of the difference between the contralateral side and the perihematomal region at 24 h (Rs = -0.692, P = 0.013). Conclusion Blood pressure variability after antihypertensive therapy in acute ICH is one of the influencing factors for 90-day mRS in patients. A 1-h dramatic drop in SBP and 24-h SBP SV may affect the long-term prognosis of patients by reducing whole cerebral perfusion.
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Affiliation(s)
- Xiangrong Sun
- Department of Neurology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China,*Correspondence: Xiangrong Sun,
| | - Xinyue Jv
- Department of Neurology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qi Mi
- Wusheng County People’s Hospital, Wusheng, Sichuan, China
| | - Qian Yang
- Department of Neurology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Tao Chen
- Department of Neurosurgery, Guangyuan Central Hospital, Guangyuan, Sichuan, China
| | - Guohui Jiang
- Department of Neurology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
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13
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Association Between Hyperacute Blood Pressure Variability and Hematoma Expansion After Intracerebral Hemorrhage: Secondary Analysis of the FAST-MAG Database. Neurocrit Care 2022; 38:356-364. [PMID: 36471183 DOI: 10.1007/s12028-022-01657-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 11/17/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Blood pressure variability (BPV) has emerged as a significant factor associated with clinical outcomes after intracerebral hemorrhage (ICH). Although hematoma expansion (HE) is associated with clinical outcomes, the relationship between BPV that encompasses prehospital data and HE is unknown. We hypothesized that BPV was positively associated with HE. METHODS We analyzed 268 patients with primary ICH enrolled in the National Institutes of Health-funded Field Administration of Stroke Therapy-Magnesium (FAST-MAG) study who received head computed tomography or magnetic resonance imaging on arrival to the emergency department (ED) and repeat imaging within 6-48 h. BPV was calculated by standard deviation (SD) and coefficient of variation (CV) from prehospital data as well as systolic blood pressure (SBP) measurements taken on ED arrival, 15 min post antihypertensive infusion start, 1 h post maintenance infusion start, and 4 h after ED arrival. HE was defined by hematoma volume expansion increase > 6 mL or by 33%. Univariate logistic regression was used for presence of HE in quintiles of SD and CV of SBP for demographics and clinical characteristics. RESULTS Of the 268 patients analyzed from the FAST-MAG study, 116 (43%) had HE. Proportions of patients with HE were not statistically significant in the higher quintiles of the SD and CV of SBP for either the hyperacute or the acute period. Presence of HE was significantly more common in patients on anticoagulation. CONCLUSIONS Higher BPV was not found to be associated with occurrence of HE in the hyperacute or the acute period of spontaneous ICH. Further study is needed to determine the relationship.
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Chen XY, Wang MH, Xiao X, Dong YH, Tan B, Dong HR, Zhou LN, Zhao JL, Xie R. Blood Pressure Variability Associates with Six-Month Outcomes in Acute Cervical Spinal Cord Injury: An Analysis of 105 Patients. World Neurosurg 2022; 168:e480-e489. [DOI: 10.1016/j.wneu.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 10/03/2022] [Indexed: 11/11/2022]
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15
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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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Advances in Intracranial Hemorrhage. Crit Care Clin 2022; 39:71-85. [DOI: 10.1016/j.ccc.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Time course of beat-to-beat blood pressure variability and outcome in patients with spontaneous intracerebral haemorrhage. J Hypertens 2022; 40:1744-1750. [PMID: 35943102 DOI: 10.1097/hjh.0000000000003206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Increased blood pressure variability (BPV) over 24 h or longer was associated with poor clinical outcomes in patients with intracerebral haemorrhage (ICH). However, the characteristics of beat-to-beat BPV, a rapid assessment of BPV and its association with outcome in ICH patients remain unknown. METHODS We consecutively and prospectively recruited patients with ICH between June 2014 and December 2020. Five-minute noninvasive beat-to-beat recordings were measured serially at three time points, 1-2, 4-6 and 10-12 days after ICH onset. BPV was calculated using standard deviation (SD) and variation independent of mean (VIM). Favourable outcome was defined as modified Rankin Scale score of less than 2 at 90 days. RESULTS The analysis included 66 participants (54.12 ± 10.79 years; 71.2% men) and 66 age and sex-matched healthy controls. Compared with that in healthy adults, beat-to-beat BPV was significantly increased 1-2 days after ICH and was completely recovered 10-12 days later. BPV recorded 1-2 days after ICH onset was higher among patients with unfavourable outcomes than among those with favourable outcomes (all P < 0.05) and higher BPV on days 1-2 was independently associated with a 3-month unfavourable outcome after adjustment for major covariates. CONCLUSION Beat-to-beat BPV was significantly increased among patients with ICH and could be completely recovered 10-12 days later. In addition, beat-to-beat BPV 1-2 days after ICH was independently associated with prognosis and could be regarded as a potential prognostic predictor and effective therapeutic target in the future.
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Tran Q, Frederick H, Tran C, Baqai H, Lurie T, Solomon J, Aligabi A, Olexa J, Cardona S, Bodanapally U, Schwartzbauer G, Downing J. Blood Pressure Variability and Outcome in Traumatic Brain Injury: A Propensity Score Matching Study. West J Emerg Med 2022; 23:769-780. [PMID: 36205663 PMCID: PMC9541979 DOI: 10.5811/westjem.2022.6.55549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 06/27/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction Patients with tIPH (used here to refer to traumatic intraparenchymal hemorrhagic contusion) or intraparenchymal hemorrhage face high rates of mortality and persistent functional deficits. Prior studies have found an association between blood pressure variability (BPV) and neurologic outcomes in patients with spontaneous IPH. Our study investigated the association between BPV and discharge destination (a proxy for functional outcome) in patients with tIPH. Methods We retrospectively reviewed the charts of patients admitted to a Level I trauma center for ≥ 24 hours with tIPH. We examined variability in hourly BP measurements over the first 24 hours of hospitalization. Our outcome of interest was discharge destination (home vs facility). We performed 1:1 propensity score matching and multivariate regressions to identify demographic and clinical factors predictive of discharge home. Results We included 354 patients; 91 were discharged home and 263 to a location other than home. The mean age was 56 (SD 21), 260 (73%) were male, 22 (6%) were on anticoagulation, and 54 (15%) on antiplatelet therapy. Our propensity-matched cohorts included 76 patients who were discharged home and 76 who were discharged to a location other than home. One measure of BPV (successive variation in systolic BP) was identified as an independent predictor of discharge location in our propensity-matched cohorts (odds ratio 0.89, 95% confidence interval 0.8–0.98; P = 0.02). Our model demonstrated good goodness of fit (P-value for Hosmer-Lemeshow test = 0.88) and very good discriminatory capability (AUROC = 0.81). High Glasgow Coma Scale score at 24 hours and treatment with fresh frozen plasma were also associated with discharge home. Conclusion Our study suggests that increased BPV is associated with lower rates of discharge home after initial hospitalization among patients with tIPH. Additional research is needed to evaluate the impact of BP control on patient outcomes.
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Affiliation(s)
- Quincy Tran
- University of Maryland School of Medicine, Baltimore, Maryland; University of Maryland School of Medicine, Research Associate Program in Emergency Medicine & Critical Care, Department of Emergency Medicine, Baltimore, Maryland; The R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland; University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - Hannah Frederick
- University of Maryland School of Medicine, Research Associate Program in Emergency Medicine & Critical Care, Department of Emergency Medicine, Baltimore, Maryland
| | - Cecilia Tran
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Hammad Baqai
- University of Maryland School of Medicine, Research Associate Program in Emergency Medicine & Critical Care, Department of Emergency Medicine, Baltimore, Maryland
| | - Tucker Lurie
- University of Maryland School of Medicine, Research Associate Program in Emergency Medicine & Critical Care, Department of Emergency Medicine, Baltimore, Maryland; Wellspan York Hospital, Department of Emergency Medicine, York, Pennsylvania
| | - Julianna Solomon
- University of Maryland School of Medicine, Research Associate Program in Emergency Medicine & Critical Care, Department of Emergency Medicine, Baltimore, Maryland
| | - Ayah Aligabi
- University of Maryland School of Medicine, Research Associate Program in Emergency Medicine & Critical Care, Department of Emergency Medicine, Baltimore, Maryland
| | - Joshua Olexa
- University of Maryland School of Medicine, Department of Neurosurgery, Baltimore, Maryland
| | - Stephanie Cardona
- Mount Sinai Hospital, Department of Critical Care Medicine, York, New York
| | - Uttam Bodanapally
- The R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Gary Schwartzbauer
- The R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland; University of Maryland School of Medicine, Department of Neurosurgery, Baltimore, Maryland
| | - Jessica Downing
- The R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Program in Trauma/Surgical Critical Care, Baltimore, Maryland
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Alshaya AI, Alghamdi M, Almohareb SN, Alshaya OA, Aldhaeefi M, Alharthi AF, Almohaish S. Systolic Blood Pressure Variability When Transitioning From Intravenous to Enteral Antihypertensive Agents in Patients With Hemorrhagic Strokes. Front Neurol 2022; 13:866557. [PMID: 35847224 PMCID: PMC9284227 DOI: 10.3389/fneur.2022.866557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 05/23/2022] [Indexed: 11/13/2022] Open
Abstract
Background/ObjectiveSystolic blood pressure variability (SBPV) in patients with intracranial hemorrhage (ICH) and subarachnoid hemorrhage (SAH) is associated with an increased risk of acute kidney injury (AKI) and mortality. SBPV is a strong predictor of poor functional outcomes in patients with ICH. Intravenous (IV) antihypertensive agents are commonly used to achieve sustained target blood pressure goals; however, this is not a feasible long-term option. The transition from IV to enteral antihypertensives is not yet well established in patients with ICH and SAH. This study aimed to assess the effect of the number of antihypertensive agents and overlap time during the transition period from IV to enteral route on SBPV in patients with ICH and SAH.MethodsThis retrospective single-center study was conducted at a tertiary teaching hospital in Riyadh, Saudi Arabia. Data were extracted from electronic medical records after obtaining Institutional Review Board approval. Patients were included if they were >18 years old, admitted with spontaneous ICH or SAH, and received continuous infusion antihypertensives prior to transitioning to the enteral route. The major outcome was the effect of the number of antihypertensive agents and overlap time on SBPV during the transition process. Minor outcomes included the effect of the number of antihypertensive agents and overlap time on heart rate variability and the incidence of AKI on day 7.ResultsAfter the screening, we included 102 patients. Based on our regression model, the number of enteral antihypertensive agents upon transitioning from IV to enteral antihypertensive therapy had no effect on SBPV in the intensive care unit (ICU) among our patients (p-value = 0.274). However, the prolonged overlap was associated with reduced SBPV in the ICU (p-value = 0.012). No differences were observed between the groups in heart rate variation or AKI rate.ConclusionsIn patients with ICH and SAH, prolonged overlap of enteral antihypertensive agents to overlap with intravenous antihypertensive therapy may result in lower SBPV. This finding needs to be confirmed on a larger scale with more robust study designs for patients with ICH and SAH.
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Affiliation(s)
- Abdulrahman I. Alshaya
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- *Correspondence: Abdulrahman I. Alshaya ; orcid.org/0000-0002-5262-5841
| | - Meshari Alghamdi
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Sumaya N. Almohareb
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Omar A. Alshaya
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Mohammed Aldhaeefi
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Clinical and Administrative Pharmacy Sciences, College of Pharmacy, Howard University, Washington, DC, United States
| | - Abdullah F. Alharthi
- King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Sulaiman Almohaish
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, VA, United States
- Pharmacy Practice Department, College of Clinical Pharmacy, King Faisal University, Hofuf, Saudi Arabia
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20
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Naito Y, Morishima N, Oyama H, Iwai K. Inhibitors of early mobilization in the acute phase of intracerebral hemorrhage: A retrospective observational study. J Stroke Cerebrovasc Dis 2022; 31:106592. [PMID: 35780720 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106592] [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: 05/02/2022] [Revised: 05/30/2022] [Accepted: 06/01/2022] [Indexed: 10/17/2022] Open
Abstract
OBJECTIVES The association between early mobilization and functional prognosis in the acute phase of intracerebral hemorrhage has been reported, but only a few studies have investigated the inhibitors of early mobilization in the acute phase of intracerebral hemorrhage. This study aimed to investigate the inhibitors of early mobilization. MATERIALS AND METHODS The study enrolled 322 patients with intracerebral hemorrhage. In the early mobilization group, mobilization was started within 72 h from onset, and in the delayed mobilization group, mobilization was started at or after 72 h from onset. The association between the start of mobilization timing and baseline characteristics was investigated using univariate and multivariate analyses to clarify the inhibitors of early mobilization in the acute phase of intracerebral hemorrhage. RESULTS Significant differences between the early mobilization and delayed mobilization groups were observed in the lesion site, leukocyte count at admission, neutrophil count at admission, C-reactive protein level at admission, surgery, use of mechanical ventilation, consciousness level at admission, hematoma volume, and hematoma growth. In the multiple logistic regression analysis, five items were adopted, namely, low consciousness level at admission, lesion below the tent, surgery, C-reactive protein at admission, and hematoma growth. CONCLUSIONS In this study, low consciousness level at admission, lesion below the tent, surgery, C-reactive protein level at admission, and hematoma growth affected delayed mobilization. Therefore, it is recommended to judge the start of mobilization timing by a systematic evidenced-based assessment for each case.
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Affiliation(s)
| | | | - Hirohumi Oyama
- Department of Neurosurgery, Toyohashi Municipal Hospital.
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21
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Hawkes MA, Anderson C, Rabinstein AA. Blood Pressure Variability After Cerebrovascular Events—A Possible New Therapeutic Target: A Narrative Review. Neurology 2022; 99:150-160. [DOI: 10.1212/wnl.0000000000200856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 04/29/2022] [Indexed: 11/15/2022] Open
Abstract
Blood pressure variability, the variation of blood pressure during a certain period, results from the interaction of hemodynamic, neuronal, humoral, behavioral, and environmental factors. Cerebral autoregulation is impaired in acute cerebrovascular disease. In these patients, increased blood pressure variability may provoke or exacerbate secondary brain injury. In fact, available data showed that increased Blood pressure variability is associated with worse outcomes after acute ischemic stroke, intracerebral hemorrhage, and aneurysmal subarachnoid hemorrhage. Consequently, blood pressure variability may represent a usual modifiable therapeutic target. This concept this particularly attractive because reduction of blood pressure variability can be feasible in regions with lower resources and can be applicable to patients with various forms of acute stroke. Prospective studies are needed to further clarify the relationship between blood pressure variability and secondary brain damage, and the determinants of blood pressure variability in different clinical populations. Ultimately, cerebrovascular disease-specific randomized controlled trials aimed at reducing blood pressure variability, irrespective of the absolute blood pressure values, are needed to determine if reduction of blood pressure variability can improve outcomes in patients with acute cerebrovascular disease.
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22
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Zimmerman WD, Chang WTW. ED BP Management for Subarachnoid Hemorrhage. Curr Hypertens Rep 2022; 24:303-309. [PMID: 35608789 DOI: 10.1007/s11906-022-01199-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To review most recent literature on management of blood pressure in acute aneurysmal subarachnoid hemorrhage (SAH) and provide practice recommendations for the emergency clinician. RECENT FINDINGS There is increased risk of aneurysmal rebleeding with systolic blood pressure (SBP) greater than 160 mmHg in the acute setting. Avoiding large degrees of blood pressure variability improves clinical outcomes in aneurysmal SAH. Acute lowering of SBP to a range of 140-160 mmHg decreases risk of rebleeding while also maintaining cerebral perfusion pressure (CPP) after aneurysmal rupture. Treatment with a short acting antihypertensive agent allows for rapid titration of blood pressure (BP) and reduces BP variability. Elevations in intracranial pressure occur commonly after SAH due to increased intracranial blood volume, cerebral edema, or development of hydrocephalus. Clinicians should be familiar with changes in cerebral autoregulation and effects on CPP when treating elevated BP, in order to mitigate the risk of secondary neurological injury.
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Affiliation(s)
- W Denney Zimmerman
- Department of Neurology, University of Maryland Medical Center, Baltimore, MD, 21201, USA
| | - Wan-Tsu W Chang
- Departments of Emergency Medicine and Neurology, Program in Trauma, University of Maryland School of Medicine, 22 S. Greene St, Baltimore, MD, 21201, USA.
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23
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Huang X, Wang D, Zhang Q, Ma Y, Li S, Zhao H, Deng J, Yang J, Ren J, Xu M, Xi H, Li F, Zhang H, Xie Y, Yuan L, Hai Y, Yue M, Zhou Q, Zhou J. Development and Validation of a Clinical-Based Signature to Predict the 90-Day Functional Outcome for Spontaneous Intracerebral Hemorrhage. Front Aging Neurosci 2022; 14:904085. [PMID: 35615596 PMCID: PMC9125153 DOI: 10.3389/fnagi.2022.904085] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 04/15/2022] [Indexed: 11/23/2022] Open
Abstract
We aimed to develop and validate an objective and easy-to-use model for identifying patients with spontaneous intracerebral hemorrhage (ICH) who have a poor 90-day prognosis. This three-center retrospective study included a large cohort of 1,122 patients with ICH who presented within 6 h of symptom onset [training cohort, n = 835; internal validation cohort, n = 201; external validation cohort (center 2 and 3), n = 86]. We collected the patients’ baseline clinical, radiological, and laboratory data as well as the 90-day functional outcomes. Independent risk factors for prognosis were identified through univariate analysis and multivariate logistic regression analysis. A nomogram was developed to visualize the model results while a calibration curve was used to verify whether the predictive performance was satisfactorily consistent with the ideal curve. Finally, we used decision curves to assess the clinical utility of the model. At 90 days, 714 (63.6%) patients had a poor prognosis. Factors associated with prognosis included age, midline shift, intraventricular hemorrhage (IVH), subarachnoid hemorrhage (SAH), hypodensities, ICH volume, perihematomal edema (PHE) volume, temperature, systolic blood pressure, Glasgow Coma Scale (GCS) score, white blood cell (WBC), neutrophil, and neutrophil-lymphocyte ratio (NLR) (p < 0.05). Moreover, age, ICH volume, and GCS were identified as independent risk factors for prognosis. For identifying patients with poor prognosis, the model showed an area under the receiver operating characteristic curve of 0.874, 0.822, and 0.868 in the training cohort, internal validation, and external validation cohorts, respectively. The calibration curve revealed that the nomogram showed satisfactory calibration in the training and validation cohorts. Decision curve analysis showed the clinical utility of the nomogram. Taken together, the nomogram developed in this study could facilitate the individualized outcome prediction in patients with ICH.
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Affiliation(s)
- Xiaoyu Huang
- Department of Radiology, Lanzhou University Second Hospital, Lanzhou, China
- Second Clinical School, Lanzhou University, Lanzhou, China
- Key Laboratory of Medical Imaging of Gansu Province, Lanzhou, China
- Gansu International Scientific and Technological Cooperation Base of Medical Imaging Artificial Intelligence, Lanzhou, China
| | - Dan Wang
- Department of Radiology, Lanzhou University Second Hospital, Lanzhou, China
| | - Qiaoying Zhang
- Department of Radiology, Xi’an Central Hospital, Xi’an, China
| | - Yaqiong Ma
- Second Clinical School, Lanzhou University, Lanzhou, China
- Department of Radiology, Gansu Provincial Hospital, Lanzhou, China
| | - Shenglin Li
- Department of Radiology, Lanzhou University Second Hospital, Lanzhou, China
- Second Clinical School, Lanzhou University, Lanzhou, China
- Key Laboratory of Medical Imaging of Gansu Province, Lanzhou, China
- Gansu International Scientific and Technological Cooperation Base of Medical Imaging Artificial Intelligence, Lanzhou, China
| | - Hui Zhao
- Department of Radiology, Lanzhou University Second Hospital, Lanzhou, China
- Second Clinical School, Lanzhou University, Lanzhou, China
- Key Laboratory of Medical Imaging of Gansu Province, Lanzhou, China
- Gansu International Scientific and Technological Cooperation Base of Medical Imaging Artificial Intelligence, Lanzhou, China
| | - Juan Deng
- Department of Radiology, Lanzhou University Second Hospital, Lanzhou, China
- Second Clinical School, Lanzhou University, Lanzhou, China
- Key Laboratory of Medical Imaging of Gansu Province, Lanzhou, China
- Gansu International Scientific and Technological Cooperation Base of Medical Imaging Artificial Intelligence, Lanzhou, China
| | - Jingjing Yang
- Department of Radiology, Lanzhou University Second Hospital, Lanzhou, China
- Second Clinical School, Lanzhou University, Lanzhou, China
- Key Laboratory of Medical Imaging of Gansu Province, Lanzhou, China
- Gansu International Scientific and Technological Cooperation Base of Medical Imaging Artificial Intelligence, Lanzhou, China
| | | | - Min Xu
- Department of Radiology, Lanzhou University Second Hospital, Lanzhou, China
- Second Clinical School, Lanzhou University, Lanzhou, China
- Key Laboratory of Medical Imaging of Gansu Province, Lanzhou, China
- Gansu International Scientific and Technological Cooperation Base of Medical Imaging Artificial Intelligence, Lanzhou, China
| | - Huaze Xi
- Department of Radiology, Lanzhou University Second Hospital, Lanzhou, China
- Second Clinical School, Lanzhou University, Lanzhou, China
- Key Laboratory of Medical Imaging of Gansu Province, Lanzhou, China
- Gansu International Scientific and Technological Cooperation Base of Medical Imaging Artificial Intelligence, Lanzhou, China
| | - Fukai Li
- Department of Radiology, Lanzhou University Second Hospital, Lanzhou, China
- Second Clinical School, Lanzhou University, Lanzhou, China
- Key Laboratory of Medical Imaging of Gansu Province, Lanzhou, China
- Gansu International Scientific and Technological Cooperation Base of Medical Imaging Artificial Intelligence, Lanzhou, China
| | - Hongyu Zhang
- Department of Radiology, Lanzhou University Second Hospital, Lanzhou, China
- Second Clinical School, Lanzhou University, Lanzhou, China
- Key Laboratory of Medical Imaging of Gansu Province, Lanzhou, China
- Gansu International Scientific and Technological Cooperation Base of Medical Imaging Artificial Intelligence, Lanzhou, China
| | - Yijing Xie
- Department of Radiology, Lanzhou University Second Hospital, Lanzhou, China
- Second Clinical School, Lanzhou University, Lanzhou, China
- Key Laboratory of Medical Imaging of Gansu Province, Lanzhou, China
- Gansu International Scientific and Technological Cooperation Base of Medical Imaging Artificial Intelligence, Lanzhou, China
| | - Long Yuan
- Department of Radiology, Lanzhou University Second Hospital, Lanzhou, China
- Second Clinical School, Lanzhou University, Lanzhou, China
- Key Laboratory of Medical Imaging of Gansu Province, Lanzhou, China
- Gansu International Scientific and Technological Cooperation Base of Medical Imaging Artificial Intelligence, Lanzhou, China
| | - Yucheng Hai
- Department of Radiology, Lanzhou University Second Hospital, Lanzhou, China
| | - Mengying Yue
- Department of Radiology, Lanzhou University Second Hospital, Lanzhou, China
| | - Qing Zhou
- Department of Radiology, Lanzhou University Second Hospital, Lanzhou, China
- Second Clinical School, Lanzhou University, Lanzhou, China
- Key Laboratory of Medical Imaging of Gansu Province, Lanzhou, China
- Gansu International Scientific and Technological Cooperation Base of Medical Imaging Artificial Intelligence, Lanzhou, China
| | - Junlin Zhou
- Department of Radiology, Lanzhou University Second Hospital, Lanzhou, China
- Key Laboratory of Medical Imaging of Gansu Province, Lanzhou, China
- Gansu International Scientific and Technological Cooperation Base of Medical Imaging Artificial Intelligence, Lanzhou, China
- *Correspondence: Junlin Zhou,
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Magid-Bernstein J, Girard R, Polster S, Srinath A, Romanos S, Awad IA, Sansing LH. Cerebral Hemorrhage: Pathophysiology, Treatment, and Future Directions. Circ Res 2022; 130:1204-1229. [PMID: 35420918 PMCID: PMC10032582 DOI: 10.1161/circresaha.121.319949] [Citation(s) in RCA: 131] [Impact Index Per Article: 65.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Intracerebral hemorrhage (ICH) is a devastating form of stroke with high morbidity and mortality. This review article focuses on the epidemiology, cause, mechanisms of injury, current treatment strategies, and future research directions of ICH. Incidence of hemorrhagic stroke has increased worldwide over the past 40 years, with shifts in the cause over time as hypertension management has improved and anticoagulant use has increased. Preclinical and clinical trials have elucidated the underlying ICH cause and mechanisms of injury from ICH including the complex interaction between edema, inflammation, iron-induced injury, and oxidative stress. Several trials have investigated optimal medical and surgical management of ICH without clear improvement in survival and functional outcomes. Ongoing research into novel approaches for ICH management provide hope for reducing the devastating effect of this disease in the future. Areas of promise in ICH therapy include prognostic biomarkers and primary prevention based on disease pathobiology, ultra-early hemostatic therapy, minimally invasive surgery, and perihematomal protection against inflammatory brain injury.
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Affiliation(s)
| | - Romuald Girard
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Sean Polster
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Abhinav Srinath
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Sharbel Romanos
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Issam A. Awad
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Lauren H. Sansing
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
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25
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Emergency department and transport predictors of neurological deterioration in patients with spontaneous intracranial hemorrhage. Am J Emerg Med 2022; 53:154-160. [DOI: 10.1016/j.ajem.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/25/2021] [Accepted: 01/02/2022] [Indexed: 11/20/2022] Open
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Prust M, Saylor D, Zimba S, Sarfo FS, Shrestha GS, Berkowitz A, Vora N. Inpatient Management of Acute Stroke of Unknown Type in Resource-Limited Settings. Stroke 2022; 53:e108-e117. [PMID: 35045720 PMCID: PMC8885836 DOI: 10.1161/strokeaha.121.037297] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Stroke is the second leading cause of death and disability worldwide, with a disproportionate burden on low- and middle-income countries. Critical elements of guideline-based stroke care developed in high-income countries are not applicable to resource-limited settings, where lack of access to neuroimaging prevents clinicians from distinguishing between ischemic stroke and intracranial hemorrhage, requiring challenging clinical decision-making, particularly in the acute setting. We discuss strategies for acute inpatient management of stroke of unknown type with a focus on blood pressure management and antiplatelet therapy when neuroimaging is unavailable, and review some of the challenges and strategies for successfully implementing stroke unit care in resource-limited health care settings.
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Affiliation(s)
| | - Deanna Saylor
- Johns Hopkins University Hospital, Baltimore, MD, USA,University Teaching Hospital, Lusaka, Zambia
| | | | | | | | - Aaron Berkowitz
- Kaiser Permanente Bernard J Tyson School of Medicine, Pasadena, CA, USA
| | - Nirali Vora
- Stanford University Medical Center, Stanford, CA, USA
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27
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Brown CS, Oliveira J E Silva L, Mattson AE, Cabrera D, Farrell K, Gerberi DJ, Rabinstein AA. Comparison of Intravenous Antihypertensives on Blood Pressure Control in Acute Neurovascular Emergencies: A Systematic Review. Neurocrit Care 2022; 37:435-446. [PMID: 34993849 DOI: 10.1007/s12028-021-01417-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 11/30/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Acute blood pressure (BP) management in neurologic patients is paramount. Different neurologic emergencies dictate various BP goals. There remains a lack of literature determining the optimal BP regimen regarding safety and efficacy. The objective of this study was to identify which intravenous antihypertensive is the most effective and safest for acute BP management in neurologic emergencies. METHODS Ovid EBM (Evidence Based Medicine) Reviews, Ovid Embase, Ovid Medline, Scopus, and Web of Science Core Collection were searched from inception to August 2020. Randomized controlled trials or comparative observational studies that evaluated clevidipine, nicardipine, labetalol, esmolol, or nitroprusside for acute neurologic emergencies were included. Outcomes of interest included mortality, functional outcome, BP variability, time to goal BP, time within goal BP, incidence of hypotension, and need for rescue antihypertensives. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to evaluate the degree of certainty in the evidence available. RESULTS A total of 3878 titles and abstracts were screened, and 183 articles were selected for full-text review. Ten studies met the inclusion criteria; however, the significant heterogeneity and very low quality of studies precluded a meta-analysis. All studies included nicardipine. Five studies compared nicardipine with labetalol, three studies compared nicardipine with clevidipine, and two studies compared nicardipine with nitroprusside. Compared with labetalol, nicardipine appears to reach goal BP faster, have less BP variability, and need less rescue antihypertensives. Compared with clevidipine, nicardipine appears to reach goal BP goal slower. Lastly, nicardipine appears to be similar for BP-related outcomes when compared with nitroprusside; however, nitroprusside may be associated with increased mortality. The confidence in the evidence available for all the outcomes was deemed very low. CONCLUSIONS Because of the very low quality of evidence, an optimal BP agent for the treatment of patients with neurologic emergencies was unable to be determined. Future randomized controlled trials are needed to compare the most promising agents.
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Affiliation(s)
- Caitlin S Brown
- Department of Pharmacy Services, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | | | - Alicia E Mattson
- Department of Pharmacy Services, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Daniel Cabrera
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kyle Farrell
- Creighton University School of Medicine, Creighton University, Omaha, NE, USA
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28
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Chen Y, Chang J, Wei J, Feng M, Wang R. Assessing the Evolution of Intracranial Hematomas by using Animal Models: A Review of the Progress and the Challenges. Metab Brain Dis 2021; 36:2205-2214. [PMID: 34417943 DOI: 10.1007/s11011-021-00828-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/14/2021] [Indexed: 01/07/2023]
Abstract
Stroke has become the second leading cause of death in people aged higher than 60 years, with cancer being the first. Intracerebral hemorrhage (ICH) is the most lethal type of stroke. Using imaging techniques to evaluate the evolution of intracranial hematomas in patients with hemorrhagic stroke is worthy of ongoing research. The difficulty in obtaining ultra-early imaging data and conducting intensive dynamic radiographic imaging in actual clinical settings has led to the application of experimental animal models to assess the evolution of intracranial hematomas. Herein, we review the current knowledge on primary intracerebral hemorrhage mechanisms, focus on the progress of animal studies related to hematoma development and secondary brain injury, introduce preclinical therapies, and summarize related challenges and future directions.
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Affiliation(s)
- Yihao Chen
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Jianbo Chang
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Junji Wei
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Ming Feng
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China.
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29
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Chen Y, Chen S, Chang J, Wei J, Feng M, Wang R. Perihematomal Edema After Intracerebral Hemorrhage: An Update on Pathogenesis, Risk Factors, and Therapeutic Advances. Front Immunol 2021; 12:740632. [PMID: 34737745 PMCID: PMC8560684 DOI: 10.3389/fimmu.2021.740632] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 09/27/2021] [Indexed: 11/26/2022] Open
Abstract
Intracerebral hemorrhage (ICH) has one of the worst prognoses among patients with stroke. Surgical measures have been adopted to relieve the mass effect of the hematoma, and developing targeted therapy against secondary brain injury (SBI) after ICH is equally essential. Numerous preclinical and clinical studies have demonstrated that perihematomal edema (PHE) is a quantifiable marker of SBI after ICH and is associated with a poor prognosis. Thus, PHE has been considered a promising therapeutic target for ICH. However, the findings derived from existing studies on PHE are disparate and unclear. Therefore, it is necessary to classify, compare, and summarize the existing studies on PHE. In this review, we describe the growth characteristics and relevant underlying mechanism of PHE, analyze the contributions of different risk factors to PHE, present the potential impact of PHE on patient outcomes, and discuss the currently available therapeutic strategies.
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Affiliation(s)
- Yihao Chen
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Shengpan Chen
- Department of Neurosurgery, Guangdong Provincial People's Hospital, Guangdong Institute of Neuroscience, Guangdong Academy of Medical Sciences, Guangdong, China
| | - Jianbo Chang
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Junji Wei
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Ming Feng
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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30
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The First 24 h Hemodynamic Management in NICU after Revascularization Surgery in Moyamoya Disease. Behav Neurol 2021; 2021:5061173. [PMID: 34691282 PMCID: PMC8536456 DOI: 10.1155/2021/5061173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 09/25/2021] [Indexed: 11/18/2022] Open
Abstract
Objective To evaluate whether hemodynamic factors are risk factors for prognosis in moyamoya disease (MMD). Materials and Methods The retrospective study reviewed a single-center MMD cohort in Huashan Hospital from August 2017 to January 2020. Stroke events in 30 days and follow-up modified Rankin Scale (mRS) grade were recorded. Systematic assessments with perioperative mean arterial pressure (MAP), red blood cell (RBC) parameters, and fluid management were also conducted. Logistic regressions were applied to evaluate the predictors of worse outcomes. Data was analyzed using SPSS 24.0. Results Admission to neurological intensive care unit (NICU) totalled about 347 after revascularization surgery. The result showed that the higher the postoperative MAP level (favorable group 95.7 ± 11.4 mmHg vs. unfavorable group 103.6 ± 10.4 mmHg, p < 0.001) and the greater the MAP variability (favorable group 0.26 ± 13.2 vs. unfavorable group 7.2 ± 13.5, p = 0.006) were, the higher the patient's follow-up mRS grade was. What is more, a higher early postoperative Hb level also seemed to predict a worse long-term clinical outcome (favorable group 116.9 ± 17.1 g/L vs. unfavorable group 123.7 ± 13.0 g/L, p = 0.03), but the difference disappeared after adjusting sex and age. Logistic regression analyses showed that a higher level of postoperative MAP (β = 0.024, 95% CI (0.004, 0.044), and p = 0.02) within the first 24 h in NICU might be the short-term risk factor. For long-term outcome, a higher level (β = 1.058, 95% CI (1.022, 1.096), and p = 0.001) and a greater variability (β = 30.982, 95% CI (2.112, 454.414), and p = 0.01) of postoperative MAP might be the negative predictors of mRS grade. Conclusions The early postoperative hemodynamic management might be extremely critical for patients with MMD. Both high postoperative MAP levels and large MAP variability might affect the prognosis. What is more, we also found that a higher postoperative Hb level might be related with a worse outcome.
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Nepal G, Shrestha GS, Shing YK, Muha A, Bhagat R. Systolic blood pressure variability following endovascular thrombectomy and clinical outcome in acute ischemic stroke: A meta-analysis. Acta Neurol Scand 2021; 144:343-354. [PMID: 34110006 DOI: 10.1111/ane.13480] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/26/2021] [Accepted: 05/14/2021] [Indexed: 12/11/2022]
Abstract
Blood pressure variability (BPV) has been linked with the outcome of acute ischemic stroke (AIS) after endovascular thrombectomy (EVT). However, the association of the stroke outcome with specific short-term BPV parameters is unclear. We did a systematic literature search for studies published from January 2010 to September 2020. Eligibility criteria included studies with (1) AIS patients treated with EVT with or without thrombolysis; and (2) analysis of the association between short-term systolic BPV parameter and clinical outcomes. Systolic BPV parameters included standard deviation (SD), coefficient of Variation (CoV), successive Variation (SV), and Variation independent of mean. A total of 11 studies were meta-analyzed, comprising 3520 patients who underwent EVT. Lower odds of achieving good functional outcome at 3 months; that is, modified Rankin Scale (mRS) score ≤2 was associated with SD (OR, 0.854; p = .02), CoV (OR, 0.572; p = .04), SV (OR 0.41; p = .00) of systolic blood pressure (SBP). Likewise, higher odds of one-point increase in mRS score was associated with SD (OR 1.42; p = .03), CoV (OR 1.464; p = .00) and SV (OR 2.605; p = .00) of SBP. However, high BPV was not associated with symptomatic intracranial hemorrhage and all-cause mortality at 90 days. The association of BPV and early neurological deterioration was inconclusive. Based on the available studies, short-term systolic BPV is indicative of the clinical outcome of patients following EVT in AIS. Further research should focus on personalized blood pressure management strategies, rather than a one-size-fits-all approach.
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Affiliation(s)
- Gaurav Nepal
- Department of Internal Medicine Tribhuvan University Institute of Medicine Kathmandu Nepal
| | | | - Yow Ka Shing
- Department of Internal Medicine National University Hospital Singapore City Singapore
| | - Allison Muha
- Department of Neurology University of Louisville School of Medicine Louisville KY USA
| | - Riwaj Bhagat
- Department of Neurology University of Louisville School of Medicine Louisville KY USA
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Abstract
PURPOSE OF REVIEW Nontraumatic intracerebral hemorrhage (ICH) is the second most common type of stroke. This article summarizes the basic pathophysiology, classification, and management of ICH and discusses the available evidence on therapy for hematoma, hematoma expansion, and perihematomal edema. RECENT FINDINGS Current available data on potential therapeutic options for ICH are promising, although none of the trials have shown improvement in mortality rate. The literature available on reversal of anticoagulation and antiplatelet agents after an ICH and resumption of these medications is also increasing. SUMMARY ICH continues to have high morbidity and mortality. Advances in therapeutic options to target secondary brain injury from the hematoma, hematoma expansion, and perihematomal edema are increasing. Data on reversal therapy for anticoagulant-associated or antiplatelet-associated ICH and resumption of these medications are evolving.
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O'Carroll CB, Brown BL, Freeman WD. Intracerebral Hemorrhage: A Common yet Disproportionately Deadly Stroke Subtype. Mayo Clin Proc 2021; 96:1639-1654. [PMID: 33952393 DOI: 10.1016/j.mayocp.2020.10.034] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 10/14/2020] [Accepted: 10/29/2020] [Indexed: 12/29/2022]
Abstract
Spontaneous intracerebral hemorrhage (ICH) is a medical emergency and is disproportionately associated with higher mortality and long-term disability compared with ischemic stroke. The phrase "time is brain" was derived for patients with large vessel occlusion ischemic stroke in which approximately 1.9 million neurons are lost every minute. Similarly, this statement holds true for ICH patients due to a high volume of neurons that are damaged at initial onset and during hematoma expansion. Most cases of spontaneous ICH pathophysiologically stem from chronic hypertension and rupture of small perforating vessels off of larger cerebral arteries supplying deep brain structures, with cerebral amyloid angiopathy being another cause for lobar hemorrhages in older patients. Optimal ICH medical management strategies include timely diagnosis, aggressive blood pressure control, correction of underlying coagulopathy defects if present, treatment of cerebral edema, and continuous assessment for possible surgical intervention. Current strategies in the surgical management of ICH include newly developed minimally invasive techniques for hematoma evacuation, with the goal of mitigating injury to fiber tracts while accessing the clot. We review evidence-based medical and surgical management of spontaneous ICH with the overall goal of reducing neurologic injury and optimizing functional outcome.
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Affiliation(s)
| | - Benjamin L Brown
- Department of Neurologic Surgery, Ochsner Neurosciences Institute, Covington, LA
| | - W David Freeman
- Departments of Critical Care Medicine, Neurologic Surgery, and Neurology, Mayo Clinic, Jacksonville, FL
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Yen HC, Jeng JS, Cheng CH, Pan GS, Chen WS. Effects of early mobilization on short-term blood pressure variability in acute intracerebral hemorrhage patients: A protocol for randomized controlled non-inferiority trial. Medicine (Baltimore) 2021; 100:e26128. [PMID: 34032760 PMCID: PMC8154506 DOI: 10.1097/md.0000000000026128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 03/14/2021] [Accepted: 05/07/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Early out-of-bed mobilization may improve acute post-intracerebral hemorrhage (ICH) outcomes, but hemodynamic instability may be a concern. Some recent studies have showed that an increase in mean systolic blood pressure (SBP) and high blood pressure variability (BPV), high standard deviation of SBP, may lead to negative ICH outcomes. Therefore, we investigated the impact of an early mobilization (EM) protocol on mean SBP and BPV during the acute phase. METHODS The study was an assessor-blinded, randomized controlled non-inferiority study. The participants were in An Early Mobilization for Acute Cerebral Hemorrhage trial and were randomly assigned to undergo EM or a standard early rehabilitation (SER) protocol within 24 to 72 hour after ICH onset at the stroke center. The EM and SER groups each had 30 patients. 24-measurement SBP were recorded on days 2 and 3 after onset, and SBP were recorded three times daily and during rehabilitation on days 4 through 7. The two groups' mean SBP and BPV under three different time frames (days 2 and 3 during the acute phase, and days 4 through 7 during the late acute phase) were calculated and compared. RESULTS At baseline, the two groups' results were similar, with the exception being that the mean time to first out-of-bed mobilization after symptom onset was 51.60 hours (SD 14.15) and 135.02 hours (SD 33.05) for the EM group and SER group, respectively (P < .001). There were no significant differences in mean SBP and BPV during the acute and late acute phase between the two groups for the three analyses (days 2, 3, and 4 through 7) (P > .05). CONCLUSIONS It is safe to implement the EM protocol within 24 to 72 hour of onset for mild-moderate ICH patients during the acute phase.
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Affiliation(s)
- Hsiao-Ching Yen
- Division of Physical Therapy, Department of Physical Medicine and Rehabilitation
| | | | | | - Guan-Shuo Pan
- Division of Physical Therapy, Department of Physical Medicine and Rehabilitation
| | - Wen-Shiang Chen
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
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35
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Khan A, Shaikh N, Alvi Y, Gupta P, Mehdi R, Siddiqui A. Blood pressure control measured as "time in range" during initial 24 h for inpatients with spontaneous nontraumatic intracerebral haemorrhage. J Neurol Sci 2021; 426:117480. [PMID: 33984548 DOI: 10.1016/j.jns.2021.117480] [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: 01/14/2021] [Revised: 04/11/2021] [Accepted: 05/02/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE Blood pressure (BP) control is an integral part in the management of spontaneous nontraumatic intracerebral haemorrhage. The aim of this study is to propose a novel concept of blood pressure control measured as 'Time in Range'(TiR) and assess its relationship to neurological deterioration. METHOD Retrospective study of 120 patients with Intracerebral haemorrhage who were admitted within 6 h of the symptom onset. The hourly BP readings for initial 24 h were studied in the form of time in range (TiR). TiR was defined as the percentage of readings with 'in range' systolic BP (SBP 110-140mmHG) during a unit time period. TiR was correlated with mean SBP at 6,12,18 and 24 h. It was categorized dichotomously as controlled (more than 50%) or not controlled (equal to or less than 50%) and analyzed with the change in Glasgow coma scale (drop of ≥2 units) at 24 h. RESULTS Correlation of TiR with mean SBP at 6 and 24 h showed significant negative correlation [r = -0.71 (at 6 h); r = -0.88 (at 24 h); p < 0.001]. The association of TiR with neurological deterioration(ND) was measured by change in GCS; with lower TiR associated with higher chances of neurological deterioration at 12 h interval [OR 4.5(1.2-16.8); p = 0.025], but not at 24 h interval [OR 1.4 (0.34-5.44); p = 0.670]. CONCLUSION Our novel concept of 'Time in Range'(TiR) was found to be relevant in our study. Its association with mean SBP reflect its potential to be a modality of expressing control of SBP in Spontaneous Nontraumatic Intracerebral Haemorrhage.
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Affiliation(s)
- Arshee Khan
- PO Box 4545, Rashid Hospital, Umm Hurair, Dubai, United Arab Emirates.
| | - Niaz Shaikh
- PO Box 4545, Rashid Hospital, Umm Hurair, Dubai, United Arab Emirates
| | - Yasir Alvi
- Department of Community Medicine, Hamdard Institute of Medical Sciences and Research, Hamdard University, New Delhi, India
| | - Priyank Gupta
- PO Box 4545, Rashid Hospital, Umm Hurair, Dubai, United Arab Emirates
| | - Rommana Mehdi
- PO Box 4545, Rashid Hospital, Umm Hurair, Dubai, United Arab Emirates
| | - Aisha Siddiqui
- PO Box 4545, Rashid Hospital, Umm Hurair, Dubai, United Arab Emirates
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Liu W, Zhuang X, Zhang L. Prognostic Value of Blood Pressure Variability for Patients With Acute or Subacute Intracerebral Hemorrhage: A Meta-Analysis of Prospective Studies. Front Neurol 2021; 12:606594. [PMID: 33776881 PMCID: PMC7991598 DOI: 10.3389/fneur.2021.606594] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 01/15/2021] [Indexed: 11/29/2022] Open
Abstract
The results on the role of systolic blood pressure (SBP) variability in the functional outcome for patients with intracerebral hemorrhage (ICH) have been inconsistent. Hence, this meta-analysis of prospective studies was conducted to assess the association between SBP variability and poor outcomes in patients with acute or subacute ICH. PubMed, Embase, and the Cochrane Library were electronically searched for eligible studies from their inception to July 2020. The role of SBP variability assessed using standard deviation (SD), coefficient of variation (CV), successive variation (SV), average real variability (ARV), and residual standard deviation (RSD) in the risk of poor functional outcomes were assessed using odds ratio (OR) with 95% confidence interval (CI) through the random-effects model. Seven prospective studies involving 5,201 patients with ICH were selected for the final meta-analysis. Increased SBP variability was associated with an increased risk of poor functional outcomes, regardless of its assessment using SD (OR: 1.38; 95% CI: 1.14–1.68; P = 0.001), CV (OR: 1.98; 95% CI: 1.13–3.47; P = 0.017), SV (OR: 1.30; 95% CI: 1.08–1.58; P = 0.006), ARV (OR: 1.13; 95% CI: 1.03–1.24; P = 0.010), or RSD (OR: 1.22; 95% CI: 1.00–1.50; P = 0.049). Moreover, the role of SBP variability in the risk of poor functional outcomes for patients with ICH was affected by country, study design, mean age, stroke type, outcome definition, and study quality. This study indicated that SBP variability was a predictor of poor outcomes for patients with ICH.
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Affiliation(s)
- Weidong Liu
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, China
| | - Xianbo Zhuang
- Department of Neurology, Liaocheng People's Hospital, Liaocheng, China
| | - Liyong Zhang
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, China
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Neurological Critical Care: The Evolution of Cerebrovascular Critical Care. Crit Care Med 2021; 49:881-900. [PMID: 33653976 DOI: 10.1097/ccm.0000000000004933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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38
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Li Y, Zhou H, Yang X, Zheng J, Zhang F, Xu M, Li H. Neck Circumference Is Associated With Poor Outcome in Patients With Spontaneous Intracerebral Hemorrhage. Front Neurol 2021; 11:622476. [PMID: 33597913 PMCID: PMC7882541 DOI: 10.3389/fneur.2020.622476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 12/29/2020] [Indexed: 02/05/2023] Open
Abstract
Objective: This study aimed to assess the association between neck circumference (NC) and functional outcome in intracerebral hemorrhage (ICH) patients. Methods: We prospectively analyzed data from ICH patients who received treatment at our institution from January 2018 to November 2019. Patients were categorized into two groups according to 180-day modified Rankin scale (MRS) scores. Univariate and multivariate analyses were performed to assess whether NC was associated with poor outcome in ICH patients. Receiver operating characteristic (ROC) curve analysis was performed to determine the significance of NC in predicting the functional outcome of ICH patients. Results: A total of 312 patients were enrolled in our study. Multivariate logistic regression analysis indicated that NC was an independent predictor of poor 180-day functional outcome [odds ratio (OR) = 1.205, 95% confidence interval (CI): 1.075–1.350, p = 0.001]. ROC analysis revealed that NC could predict poor functional outcome at 6 months. Conclusions: NC is an independent predictor of unfavorable functional outcome at 6 months in ICH patients.
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Affiliation(s)
- Yujian Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Huiqing Zhou
- Department of Intensive Care Unit, Fourth People's Hospital of Sichuan Province, Chengdu, China
| | - Xiang Yang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jun Zheng
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Fan Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Mangmang Xu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Hao Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
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Optimal Hemodynamic Parameters for Brain-injured Patients in the Clinical Setting: A Narrative Review of the Evidence. J Neurosurg Anesthesiol 2021; 34:288-299. [PMID: 33443353 DOI: 10.1097/ana.0000000000000752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 12/07/2020] [Indexed: 11/25/2022]
Abstract
Defining optimal hemodynamic targets for brain-injured patients is a challenging undertaking. The physiological interference observed in various intracranial pathologies can have varying effects on cerebral physiology at different time points. This narrative review provides an overview of cerebral autoregulatory physiology and common misconceptions, and examines the physiological considerations and clinical evidence for determining optimal hemodynamic parameters in acutely brain-injured patients with relevance to modern neuroanesthesia and neurocritical care practice.
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40
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Tran QK, Najafali D, Tiffany L, Tanveer S, Andersen B, Dawson M, Hausladen R, Jackson M, Matta A, Mitchell J, Yum C, Kuhn D. Effect of Blood Pressure Variability on Outcomes in Emergency Patients with Intracranial Hemorrhage. West J Emerg Med 2021; 22:177-185. [PMID: 33856298 PMCID: PMC7972364 DOI: 10.5811/westjem.2020.9.48072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 09/26/2020] [Indexed: 12/02/2022] Open
Abstract
Introduction Patients with spontaneous intracranial hemorrhage (sICH) have high mortality and morbidity, which are associated with blood pressure variability. Additionally, blood pressure variability is associated with acute kidney injury (AKI) in critically ill patients, but its association with sICH patients in emergency departments (ED) is unclear. Our study investigated the association between blood pressure variability in the ED and the risk of developing AKI during sICH patients’ hospital stay. Methods We retrospectively analyzed patients with sICH, including those with subarachnoid and intraparenchymal hemorrhage, who were admitted from any ED and who received an external ventricular drain at our academic center. Patients were identified by the International Classification of Diseases, Ninth Revision (ICD-9). Outcomes were the development of AKI, mortality, and being discharged home. We performed multivariable logistic regressions to measure the association of clinical factors and interventions with outcomes. Results We analyzed the records of 259 patients: 71 (27%) patients developed AKI, and 59 (23%) patients died. Mean age (± standard deviation [SD]) was 58 (14) years, and 150 (58%) were female. Patients with AKI had significantly higher blood pressure variability than patients without AKI. Each millimeter of mercury increment in one component of blood pressure variability, SD in systolic blood pressure (SBPSD), was significantly associated with 2% increased likelihood of developing AKI (odds ratio [OR] 1.02, 95% confidence interval [CI], 1.005–1.03, p = 0.007). Initiating nicardipine infusion in the ED (OR 0.35, 95% CI, 0.15–0.77, p = 0.01) was associated with lower odds of in-hospital mortality. No ED interventions or blood pressure variability components were associated with patients’ likelihood to be discharged home. Conclusion Our study suggests that greater SBPSD during patients’ ED stay is associated with higher likelihood of AKI, while starting nicardipine infusion is associated with lower odds of in-hospital mortality. Further studies about interventions and outcomes of patients with sICH in the ED are needed to confirm our observations.
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Affiliation(s)
- Quincy K Tran
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland.,University of Maryland School of Medicine, The R Adams Cowley Shock Trauma Center, Department of Emergency Medicine, Baltimore, Maryland.,University of Maryland School of Medicine, The Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, Baltimore, Maryland
| | - Daniel Najafali
- University of Maryland School of Medicine, The Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, Baltimore, Maryland
| | - Laura Tiffany
- University of Maryland School of Medicine, The Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, Baltimore, Maryland
| | - Safura Tanveer
- University of Maryland School of Medicine, The Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, Baltimore, Maryland
| | - Brooke Andersen
- University of Maryland School of Medicine, The R Adams Cowley Shock Trauma Center, Department of Emergency Medicine, Baltimore, Maryland
| | - Michelle Dawson
- University of Maryland School of Medicine, The R Adams Cowley Shock Trauma Center, Department of Emergency Medicine, Baltimore, Maryland
| | - Rachel Hausladen
- University of Maryland Medical Center, Department of Neurology, Baltimore, Maryland
| | - Matthew Jackson
- University of Maryland School of Medicine, The Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, Baltimore, Maryland
| | - Ann Matta
- University of Maryland School of Medicine, The R Adams Cowley Shock Trauma Center, Department of Emergency Medicine, Baltimore, Maryland
| | - Jordan Mitchell
- University of Maryland School of Medicine, The Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, Baltimore, Maryland
| | - Christopher Yum
- University of Maryland School of Medicine, The Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, Baltimore, Maryland
| | - Diane Kuhn
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
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Abstract
Hemorrhagic stroke comprises about 20% of all strokes, with intracerebral hemorrhage (ICH) being the most common type. Frequency of ICH is increased where hypertension is untreated. ICH in particularly has a disproportionately high risk of early mortality and long-term disability. Until recently, there has been a paucity of randomized controlled trials (RCTs) to provide evidence for the efficacy of various commonly considered interventions in ICH, including acute blood pressure management, coagulopathy reversal, and surgical hematoma evacuation. Evidence-based guidelines do exist for ICH and these form the basis for a framework of care. Current approaches emphasize control of extremely high blood pressure in the acute phase, rapid reversal of vitamin K antagonists, and surgical evacuation of cerebellar hemorrhage. Lingering questions, many of which are the topic of ongoing clinical research, include optimizing individual blood pressure targets, reversal strategies for newer anticoagulant medications, and the role of minimally invasive surgery. Risk stratification models exist, which derive from findings on clinical exam and neuroimaging, but care should be taken to avoid a self-fulfilling prophecy of poor outcome from limiting treatment due to a presumed poor prognosis. Cerebral venous thrombosis is an additional subtype of hemorrhagic stroke that has a unique set of causes, natural history, and treatment and is discussed as well.
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Affiliation(s)
- Arturo Montaño
- Departments of Neurology and Neurosurgery, University of Colorado, Aurora, CO, United States
| | - Daniel F Hanley
- Departments of Neurology and Neurosurgery, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - J Claude Hemphill
- Departments of Neurology and Neurosurgery, University of California San Francisco, San Francisco, CA, United States.
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Kim SM, Woo HG, Kim YJ, Kim BJ. Blood pressure management in stroke patients. JOURNAL OF NEUROCRITICAL CARE 2020. [DOI: 10.18700/jnc.200028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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43
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Guo ZN, Qu Y, Reziya H, Liu J, Yan XL, Zhang P, Zhang PD, Qi S, Yang Y. Which Parameters of Beat-to-Beat Blood Pressure Best Predict Poor In-Hospital Outcome in Spontaneous Intracerebral Hemorrhage? Front Aging Neurosci 2020; 12:603340. [PMID: 33328978 PMCID: PMC7710867 DOI: 10.3389/fnagi.2020.603340] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 10/26/2020] [Indexed: 11/29/2022] Open
Abstract
Objective: There is increasing evidence that high blood pressure (BP) levels and BP variability (BPV) over 24 h or longer are associated with poor clinical outcomes in patients with intracerebral hemorrhage (ICH). The objective of this study was to examine the association between different beat-to-beat BP parameters and in-hospital outcomes. Methods: Patients with a diagnosis of acute spontaneous ICH were recruited consecutively and prospectively between September 2018 and January 2019. Beat-to-beat recordings were measured non-invasively for 5 min within the first 72 h after the onset of symptoms. BPV was analyzed by standard deviation (SD), coefficient of variation (CV), average real variability (ARV), and variation independent of mean (VIM). Outcome was assessed at discharge using the modified Rankin Scale (mRS) score. Multivariate logistic regression analysis was used to assess the association between BP levels, BPV, and clinical outcomes. Results: A total of 66 patients were included, of whom 34 had poor outcomes (mRS score, 3–6). Patients with poor outcomes had significantly higher National Institute of Health Stroke Scale scores (4.5 vs. 9, p < 0.001), a larger ICH volume (8 vs. 14.5 mL, p = 0.004), and an increased systolic BP (SBP) -CV (3.2 vs. 4.8, p < 0.001) and diastolic BP (DBP) -CV (3.7 vs. 4.9, p = 0.015). After adjustment for major covariates, multivariate logistic regression analysis revealed that SBP-CV was independently associated with an increased risk of poor in-hospital outcomes [odds ratio (OR) 2.535; 95% confidence interval (CI), 1.211–5.305; p = 0.014]. The receiver operating characteristic area for SBP-CV in predicting poor in-hospital outcome was 0.827 (95% CI, 0.730–0.925; p < 0.001), and the best cutoff point was 3.551 (sensitivity, 82.35%; specificity, 68.75%). Conclusion: A higher beat-to-beat BPV in the first 72 h of admission was associated with unfavorable in-hospital outcomes in patients with ICH. The stabilization of BPV during the acute phase may be a therapeutic target; this could be tested in future clinical trials.
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Affiliation(s)
- Zhen-Ni Guo
- Department of Neurology, Stroke Center & Clinical Trial and Research Center for Stroke, The First Hospital of Jilin University, Changchun, China.,China National Comprehensive Stroke Center, Changchun, China.,Jilin Provincial Key Laboratory of Cerebrovascular Disease, Changchun, China
| | - Yang Qu
- Department of Neurology, Stroke Center & Clinical Trial and Research Center for Stroke, The First Hospital of Jilin University, Changchun, China.,China National Comprehensive Stroke Center, Changchun, China.,Jilin Provincial Key Laboratory of Cerebrovascular Disease, Changchun, China
| | - Hailili Reziya
- Department of Neurology, Stroke Center & Clinical Trial and Research Center for Stroke, The First Hospital of Jilin University, Changchun, China.,China National Comprehensive Stroke Center, Changchun, China.,Jilin Provincial Key Laboratory of Cerebrovascular Disease, Changchun, China
| | - Jia Liu
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Xiu-Li Yan
- Department of Neurology, Stroke Center & Clinical Trial and Research Center for Stroke, The First Hospital of Jilin University, Changchun, China.,China National Comprehensive Stroke Center, Changchun, China.,Jilin Provincial Key Laboratory of Cerebrovascular Disease, Changchun, China
| | - Peng Zhang
- Department of Neurology, Stroke Center & Clinical Trial and Research Center for Stroke, The First Hospital of Jilin University, Changchun, China.,China National Comprehensive Stroke Center, Changchun, China.,Jilin Provincial Key Laboratory of Cerebrovascular Disease, Changchun, China
| | - Pan-Deng Zhang
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Shuang Qi
- Department of Neurology, Stroke Center & Clinical Trial and Research Center for Stroke, The First Hospital of Jilin University, Changchun, China.,China National Comprehensive Stroke Center, Changchun, China.,Jilin Provincial Key Laboratory of Cerebrovascular Disease, Changchun, China
| | - Yi Yang
- Department of Neurology, Stroke Center & Clinical Trial and Research Center for Stroke, The First Hospital of Jilin University, Changchun, China.,China National Comprehensive Stroke Center, Changchun, China.,Jilin Provincial Key Laboratory of Cerebrovascular Disease, Changchun, China
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Andalib S, Lattanzi S, Di Napoli M, Petersen A, Biller J, Kulik T, Macri E, Girotra T, Torbey MT, Divani AA. Blood Pressure Variability: A New Predicting Factor for Clinical Outcomes of Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2020; 29:105340. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.105340] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/10/2020] [Accepted: 09/18/2020] [Indexed: 02/06/2023] Open
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45
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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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Tiffany L, Haase DJ, Boswell K, Dietrich ME, Najafali D, Olexa J, Rea J, Sapru M, Scalea T, Tran QK. Care intensity of spontaneous intracranial hemorrhage: Effectiveness of the critical care resuscitation unit. Am J Emerg Med 2020; 46:437-444. [PMID: 33172747 DOI: 10.1016/j.ajem.2020.10.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/22/2020] [Accepted: 10/22/2020] [Indexed: 11/29/2022] Open
Affiliation(s)
- Laura Tiffany
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Daniel J Haase
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA; Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA; The Critical Care Resuscitation Unit, University of Maryland Medical Center, Baltimore, MD, USA.
| | - Kimberly Boswell
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA; Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA; The Critical Care Resuscitation Unit, University of Maryland Medical Center, Baltimore, MD, USA.
| | - Mary Ellen Dietrich
- The Critical Care Resuscitation Unit, University of Maryland Medical Center, Baltimore, MD, USA.
| | - Daniel Najafali
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Joshua Olexa
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Jeffrey Rea
- Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA; The Critical Care Resuscitation Unit, University of Maryland Medical Center, Baltimore, MD, USA.
| | - Mayga Sapru
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Thomas Scalea
- Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Quincy K Tran
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA; Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA; The Critical Care Resuscitation Unit, University of Maryland Medical Center, Baltimore, MD, USA.
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47
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Al-Kawaz MN, Hanley DF, Ziai W. Advances in Therapeutic Approaches for Spontaneous Intracerebral Hemorrhage. Neurotherapeutics 2020; 17:1757-1767. [PMID: 32720246 PMCID: PMC7851203 DOI: 10.1007/s13311-020-00902-w] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Spontaneous intracerebral hemorrhage (ICH) results in high rates of morbidity and mortality, with intraventricular hemorrhage (IVH) being associated with even worse outcomes. Therapeutic interventions in acute ICH have continued to emerge with focus on arresting hemorrhage expansion, clot volume reduction of both intraventricular and parenchymal hematomas, and targeting perihematomal edema and inflammation. Large randomized controlled trials addressing the effectiveness of rapid blood pressure lowering, hemostatic therapy with platelet transfusion, and other clotting complexes and hematoma volume reduction using minimally invasive techniques have impacted clinical guidelines. We review the recent evolution in the management of acute spontaneous ICH, discussing which interventions have been shown to be safe and which may potentially improve outcomes.
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Affiliation(s)
- Mais N Al-Kawaz
- The Johns Hopkins Hospital, 1800 Orleans Street, Phipps 455, Baltimore, MD, 21287, USA
| | - Daniel F Hanley
- The Johns Hopkins Hospital, 1800 Orleans Street, Phipps 455, Baltimore, MD, 21287, USA
| | - Wendy Ziai
- The Johns Hopkins Hospital, 1800 Orleans Street, Phipps 455, Baltimore, MD, 21287, USA.
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Park JY, Park SJ, Byun SJ, Woo SJ, Park KH. Twelve-year incidence of retinal vein occlusion and its trend in Korea. Graefes Arch Clin Exp Ophthalmol 2020; 258:2095-2104. [DOI: 10.1007/s00417-020-04811-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 06/16/2020] [Accepted: 06/17/2020] [Indexed: 10/24/2022] Open
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Arrival blood pressure in hypertensive and non-hypertensive spontaneous intracerebral hemorrhage. J Neurol Sci 2020; 416:117000. [PMID: 32593888 DOI: 10.1016/j.jns.2020.117000] [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: 04/29/2020] [Revised: 06/02/2020] [Accepted: 06/16/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND PURPOSE Hypertension is a known risk factor for intracerebral hemorrhage (ICH), but it is unclear whether blood pressure (BP) at hospital arrival can be used to distinguish hypertensive ICH from non-hypertensive etiologies. PATIENTS AND METHODS We performed a single-center cohort study using data from consecutive ICH patients over 12 months. ICH characteristics including etiology were prospectively adjudicated by two attending neurologists. Using adjusted linear regression models, we compared first recorded systolic BPs (SBP) and mean arterial pressures (MAP) in patients with hypertensive vs. other ICH etiologies. We then used area under the ROC curve (AUC) analysis to determine the accuracy of admission BP in differentiating between hypertensive and non-hypertensive ICH. RESULTS Of 311 patients in our cohort (mean age 70.6 ± 15.6, 50% male, 83% white), the most frequent ICH etiologies were hypertension (50%) and cerebral amyloid angiopathy (CAA; 22%). Mean SBP and MAP for patients with hypertensive ICH was 175.1 ± 32.9 mmHg and 120.4 ± 22.9 mmHg, respectively, compared to 156.4 ± 28.0 mmHg and 109.6 ± 20.3 mmHg in non-hypertensive ICH (p < .001). Adjusted models showed that hypertensive ICH patients had higher BPs than those with CAA (mean SBP difference 10.7 mmHg [95% CI 0.8-20.5]; mean MAP difference 8.1 mmHg [1.1-15.0]) and especially patients with other non-CAA causes (mean SBP difference 23.9 mmHg [15.3-32.4]; mean MAP difference 14.5 mmHg [8.5-20.6]). However, on a patient-level, arrival BP did not reliably discriminate between hypertensive and non-hypertensive etiologies (AUC 0.660 [0.599-0.720]). CONCLUSIONS Arrival BP differs between hypertensive and non-hypertensive ICH but should not be used as a primary determinant of etiology, as hypertension may be implicated in various subtypes of ICH.
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In-hospital day-by-day systolic blood pressure variability during rehabilitation: a marker of adverse outcome in secondary prevention after myocardial revascularization. J Hypertens 2020; 38:1729-1736. [PMID: 32516294 DOI: 10.1097/hjh.0000000000002489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Although it is known that increased visit-to-visit or home day-by-day variability of blood pressure (BP), independently of its average value, results in an increased risk of cardiovascular events, the prognostic value of in-hospital day-by-day BP variability in secondary cardiovascular prevention has not yet been established. METHODS We studied 1440 consecutive cardiac patients during a cardiovascular rehabilitation program of about 12 days after coronary artery bypass graft (CABG) and/or valve surgery. We measured auscultatory BP at the patient bed in each rehabilitation day twice, in the morning and the afternoon. We correlated SBP variability assessed as standard deviation (SBP-SD) and coefficient of variation (SBP-CoV) of the daily measures with overall mortality, cardiovascular mortality and major adverse cardiocerebrovascular events (MACCEs) after a mean follow-up of 49 months by Cox hazard analysis. RESULTS In our patients (age 68 ± 11years, 61% hypertensive patients) the ranges of SBP-SD tertiles were: 4.1-9.1, 9.2-11.5 and 11.6-24.5 mmHg. Fifty-five percent of the patients underwent CABG, 33% underwent valve surgery, 12% both CABG and valve surgery. In CABG patients, the highest SBP-SD tertile showed the highest overall mortality, cardiovascular mortality and MACCEs (P < 0.01). Results remained significant after multivariate analysis adjusting for age, sex, mean SBP, BMI, hypertension, hyperlipidaemia, and diabetes. No association between SBP-SD and mortality or MACCEs was found in valve surgery patients. CONCLUSION In-hospital day-by-day SBP variability predicts mortality and MACCEs in CABG patients, possibly representing a target during rehabilitation and treatment in secondary cardiovascular prevention.
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