Associations of Early Systolic Blood Pressure Control and Outcome After Thrombolysis-Eligible Acute Ischemic Stroke: Results From the ENCHANTED Study

Baseline systolic blood pressure, hypertension history, and efficacy of remote ischemic conditioning

OBJECTIVE

We performed a post hoc exploratory analysis of Remote Ischemic Conditioning for Acute Moderate Ischemic Stroke (RICAMIS) to determine whether hypertension history and baseline systolic blood pressure (SBP) affect the efficacy of remote ischemic conditioning (RIC).

METHODS

Based on the full analysis set of RICAMIS, patients were divided into hypertension versus non-hypertension group, or <140 mmHg versus ≥140 mmHg group. Each group was further subdivided into RIC and control subgroups. The primary outcome was modified Rankin Scale (mRS) 0-1 at 90 days. Efficacy of RIC was compared among patients with hypertension versus nonhypertension history and SBP of <140 mmHg versus ≥140 mmHg. Furthermore, the interaction effect of treatment with hypertension and SBP was assessed.

RESULTS

Compared with control group, RIC produced a significantly higher proportion of patients with excellent functional outcome in the nonhypertension group (RIC vs. control: 65.7% vs. 57.0%, OR 1.45, 95% CI 1.06-1.98; p = 0.02), but no significant difference was observed in the hypertension group (RIC vs. control: 69.1% vs. 65.2%, p = 0.17). Similar results were observed in SBP ≥140 mmHg group (RIC vs. control: 68.0% vs. 61.2%, p = 0.009) and SBP <140 mmHg group (RIC vs. control: 65.6% vs. 64.7%, p = 0.77). No interaction effect of RIC on primary outcome was identified.

INTERPRETATION

Hypertension and baseline SBP did not affect the neuroprotective effect of RIC, but they were associated with higher probability of excellent functional outcome in patients with acute moderate ischemic stroke who received RIC treatment.

[Impact of the COVID-19 pandemic on cardiovascular disease mortality trends in Mexico, 2000-2022]

OBJECTIVE

To estimate the impact of the COVID-19 pandemic on cardiovascular disease (CVD) mortality trends in Mexico.

METHODS

An ecological study was conducted where deaths from CVD reported in Mexico under the ICD-10 classification with codes I10 to I99 for the period 2000-2022 were analyzed. Age-standardized mortality rates were calculated at the national and state levels, then the annual percentage variation was estimated using joinpoint analysis to know the changes in the mortality trend in the period studied.

RESULTS

There was an increase of 27.96 deaths per 100,000 inhabitants from 2000 to 2022 in Mexico. The joinpoint analysis shows in the period 2019-2021 an annual percentage change at the national level of 17,398 and subsequently a negative trend is presented between the years 2021-2022. The states of Guanajuato, Tlaxcala and Querétaro showed the largest increases in CVD mortality trends during the COVID-19 pandemic.

CONCLUSIONS

The trend in CVD mortality in Mexico increased significantly during the COVID-19 pandemic.

Intensive Blood Pressure Control After Endovascular Thrombectomy for Acute Ischemic Stroke: a Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

Optimal clinical outcome with successful recanalization from endovascular thrombectomy (EVT) requires optimal blood pressure (BP) management. We aimed to evaluate the efficacy and safety of the intensive BP target (< 140 mm Hg) versus the standard BP target (< 180 mm Hg) after EVT for acute ischemic stroke.

METHODS

We conducted a systematic review and meta-analysis synthesizing evidence from randomized controlled trials (RCTs) obtained from PubMed, Embase Cochrane, Scopus, and WOS until September 7th, 2023. We used the fixed-effect model to report dichotomous outcomes using risk ratio (RR) and continuous outcomes using mean difference (MD), with a 95% confidence interval (CI).

PROSPERO ID

CRD42023463206.

RESULTS

We included four RCTs with 1559 patients. There was no difference between intensive BP and standard BP targets regarding the National Institutes of Health Stroke Scale (NIHSS) change after 24 h [MD: 0.44 with 95% CI (0.0, 0.87), P = 0.05]. However, the intensive BP target was significantly associated with a decreased risk of excellent neurological recovery (mRS ≤ 1) [RR: 0.87 with 95% CI (0.76, 0.99), P = 0.03], functional independence (mRS ≤ 2) [RR: 0.81 with 95% CI (0.73, 0.90), P = 0.0001] and independent ambulation (mRS ≤ 3) [RR: 0.85 with 95% CI (0.79, 0.92), P < 0.0001].

CONCLUSIONS

An intensive BP target after EVT is associated with worse neurological recovery and significantly decreased rates of functional independence and independent ambulation compared to the standard BP target. Therefore, the intensive BP target should be avoided after EVT for acute ischemic stroke.

Prevalence, Risk Factors, and Clinical Outcomes of New Cerebral Microbleeds After Intravenous Thrombolysis in Acute Ischemic Stroke: a Systematic Review and Meta-analysis

BACKGROUND

Cerebral microbleeds (CMBs) are common in the elderly population, and are associated with an increased risk of stroke and dementia. An acute ischemic stroke event can make CMBs develop rapidly. However, the progression of CMBs after intravenous thrombolysis is not well understood.

METHODS

Following a previously registered protocol, PubMed, Web of Science, and Embase databases were systematically searched to identify relevant literature up to August 2022. Cohort studies that reported new CMBs in patients with acute ischemic stroke undergoing intravenous thrombolysis were included. Random effects models were used to calculate the pooled estimates.

RESULTS

Seven studies with 1079 patients were included in the meta-analysis. The pooled new CMBs prevalence was 7.6% (95% CI 3.9-14.3%) and 63.6% new CMBs were located in the cerebral lobes. Compared with patients without new CMBs, those with new CMBs were older, had a higher proportion of hypertension, and had higher systolic blood pressure and baseline CMBs burden. The presence of new CMBs increased the likelihood of remote intracerebral hemorrhage (OR 28.75, 95% CI 8.58-96.38) and symptomatic intracerebral hemorrhage (OR 15.49, 95% CI 3.21-74.73) but was not related to functional outcomes or hemorrhagic transformation.

CONCLUSIONS

The prevalence of new CMBs after intravenous thrombolysis was approximately 7.6%. The presence of new CMBs is associated with remote and symptomatic intracerebral hemorrhage following intravenous thrombolysis. Considering the potential long-term adverse effects of CMBs progression, patients at a high risk of developing new CMBs should be identified based on potential risk factors.

Association between blood pressure and different antihypertensive drugs with outcome after ischemic stroke: A Mendelian randomization study

BACKGROUND

Observational studies suggest an association between blood pressure (BP) and functional outcomes in ischemic stroke patients but whether this is causal or due to confounding is uncertain. We used Mendelian randomization (MR) to assess causality, and also explore whether particular classes of anti-hypertensives were associated with a better outcome after ischemic stroke.

METHODS

We selected genetic variants associated with systolic and diastolic BP and BP-lowering variants in genes encoding antihypertensive drugs from genome-wide association studies (GWAS) on 757,601 individuals. The primary outcome was 3-month dependence or death defined as a modified Rankin Scale (mRS) of 3-6. The secondary outcome was disability or death after 90 days defined as mRS 2-6. Cochran's Q statistic in the inverse variance weighted (IVW) model, the weighted median, MR-Egger regression, leave-one-single-nucleotide polymorphism (SNP)-out analysis, MR-Pleiotropy Residual Sum and Outlier methods were adopted as sensitivity analyses. To validate our primary results, we performed independent repeat analyses and Bi-directional MR analyses.

RESULTS

Genetic predisposition to higher systolic and diastolic BP was associated with disability or death after ischemic stroke in univariable IVW MR analysis (odds ratio (OR) 1.29, 95% confidence interval (CI): 1.05-1.59, p = 0.014; OR 1.27, 95% CI: 1.07-1.51, p = 0.006, respectively). Pulse pressure was associated with both dependence or death and disability or death after ischemic stroke (OR = 1.05, 95% CI: 1.02-1.08, p = 0.002; OR = 1.04, 95% CI = 1.01-1.07, p = 0.009, respectively). Angiotensin-converting enzyme inhibitor (ACEI) and calcium channel blocker (CCB) were significantly associated with improved functional outcomes (dependence or death, OR 0.76, 95% CI: 0.62-0.94, p = 0.009; OR 0.89, 95% CI: 0.83-0.97, p = 0.005). Proxies for β-blockers, angiotensin receptor blockers (ARB), and thiazides failed to show associations with functional outcomes (p > 0.05).

CONCLUSION

We provide evidence for an association of genetic predisposition to higher BP with a higher risk of 3-month functional dependence after ischemic stroke. Our findings support ACEI and CCB as promising antihypertensive drugs for improving functional outcomes in ischemic stroke.

Predicting 90-Day Prognosis in Ischemic Stroke Patients Post Thrombolysis Using Machine Learning

(1) Objective: This study aimed to construct a machine learning model for predicting the prognosis of ischemic stroke patients who underwent thrombolysis, assessed through the modified Rankin Scale (mRS) score 90 days after discharge. (2) Methods: Data were sourced from Qatar's stroke registry covering January 2014 to June 2022. A total of 723 patients with ischemic stroke who had received thrombolysis were included. Clinical variables were examined, encompassing demographics, stroke severity indices, comorbidities, laboratory results, admission vital signs, and hospital-acquired complications. The predictive capabilities of five distinct machine learning models were rigorously evaluated using a comprehensive set of metrics. The SHAP analysis was deployed to uncover the most influential predictors. (3) Results: The Support Vector Machine (SVM) model emerged as the standout performer, achieving an area under the curve (AUC) of 0.72. Key determinants of patient outcomes included stroke severity at admission; admission systolic and diastolic blood pressure; baseline comorbidities, notably hypertension (HTN) and coronary artery disease (CAD); stroke subtype, particularly strokes of undetermined origin (SUO); and hospital-acquired urinary tract infections (UTIs). (4) Conclusions: Machine learning can improve early prognosis prediction in ischemic stroke, especially after thrombolysis. The SVM model is a promising tool for empowering clinicians to create individualized treatment plans. Despite limitations, this study contributes to our knowledge and encourages future research to integrate more comprehensive data. Ultimately, it offers a pathway to improve personalized stroke care and enhance the quality of life for stroke survivors.

Serum uric acid and prognosis in acute ischemic stroke: a dose-response meta-analysis of cohort studies

Background

There have been contradictory findings regarding the relationship between serum uric acid levels and prognosis in acute ischemic stroke. Whether this association is nonlinear due to uric acid's paradoxical properties (antioxidant and prooxidant) is unclear.

Methods

We searched PubMed, Web of Science, and Embase databases until December 2022. Cohort studies reporting serum uric acid levels and functional outcome, mortality, or neurological complications in patients with acute ischemic stroke were included. Summary effect estimates were calculated using a random-effect model. Moreover, dose-response relationships were assessed by the generalized least squares trend estimation.

Results

Altogether, 13 cohort studies were identified in this study. Compared to the lowest baseline serum uric acid levels, the highest levels were associated with decreased risk of poor functional outcome (OR = 0.70, 95% CI 0.54-0.91, I2 = 29%), hemorrhagic transformation (OR = 0.15, 95% CI 0.05-0.42, I2 = 79%), and post-stroke depression (OR = 0.04, 95% CI 0.00-0.95, I2 = 89%), but not associated with mortality and symptomatic intracerebral hemorrhage. A nonlinear relationship was observed in poor functional outcome (U-shaped, P for nonlinearity = 0.042), hemorrhagic transformation (inverse, P for nonlinearity = 0.001), and post-stroke depression (inverse, P for nonlinearity = 0.002). In addition, there was a single study reporting a U-shaped association in post-stroke epilepsy (P for nonlinearity <0.001). Furthermore, another study reported a positive curvilinear association in stroke recurrence (P for nonlinearity <0.05). The insufficient number of original articles for some prognostic indicators should be considered when interpreting the results of this meta-analysis.

Conclusion

In patients with acute ischemic stroke, serum uric acid levels are nonlinearly associated with the risk of poor functional outcome (U-shaped). More evidence is needed to confirm the association between serum uric acid levels and neurological complications following acute ischemic stroke.

Blood pressure excursion on admission and intravenous thrombolysis in ischemic stroke

BACKGROUND

Blood pressure (BP) excursion on admission was common in patients with acute ischemic stroke, but its influence on thrombolysis effect was not fully evaluated.

METHODS

Patients with acute ischemic stroke who received thrombolysis without subsequent thrombectomy were included. Admission BP excursion was defined as higher than 185/110 mmHg. Multivariate logistic regression analysis was used to evaluate the relationship between admission BP excursion and poor outcome as well as hemorrhage rates and mortality. Poor outcome was defined as a 90-day modified Rankin Scale score 3-6. Subgroup analysis was performed according to stroke severity, which was assessed by the National Institutes of Health Stroke Scale (NIHSS) score, and hypertension status.

RESULTS

A total of 633 patients were enrolled and 240 participants (37.9%) had admission BP excursion. Admission BP excursion was associated with poor outcome [adjusted odds ratio (OR) 0.64, 95% confidence interval 0.42-0.99, P  = 0.046]. No significant difference was found regarding hemorrhage rates or mortality between patients with and without admission BP excursion. In subgroup analysis, admission BP excursion was related to poor outcome in patients with NIHSS score at least 7 (adjusted OR 1.89, 95% confidence interval 1.03-3.45, P  = 0.038), but not in patients with NIHSS score less than 7 ( P for interaction <0.001).

CONCLUSION

Admission BP excursion above the guideline thresholds did not increase postthrombolysis hemorrhage risk or mortality, but was associated with poor outcome, especially in patients with severe stroke.

Development and validation of a nomogram model for predicting unfavorable functional outcomes in ischemic stroke patients after acute phase

Introduction

Prediction of post-stroke functional outcome is important for personalized rehabilitation treatment, we aimed to develop an effective nomogram for predicting long-term unfavorable functional outcomes in ischemic stroke patients after acute phase.

Methods

We retrospectively analyzed clinical data, rehabilitation data, and longitudinal follow-up data from ischemic stroke patients who underwent early rehabilitation at multiple centers in China. An unfavorable functional outcome was defined as a modified Rankin Scale (mRS) score of 3-6 at 90 days after onset. Patients were randomly allocated to either a training or test cohort in a ratio of 4:1. Univariate and multivariate logistic regression analyses were used to identify the predictors for the development of a predictive nomogram. The area under the receiver operating characteristic curve (AUC) was used to evaluate predictive ability in both the training and test cohorts.

Results

A total of 856 patients (training cohort: n = 684; test cohort: n = 172) were included in this study. Among them, 518 patients experienced unfavorable outcomes 90 days after ischemic stroke. Trial of ORG 10172 in Acute Stroke Treatment classification (p = 0.024), antihypertensive agents use [odds ratio (OR) = 1.86; p = 0.041], 15-day Barthel Index score (OR = 0.930; p < 0.001) and 15-day mRS score (OR = 13.494; p < 0.001) were selected as predictors for the unfavorable outcome nomogram. The nomogram model showed good predictive performance in both the training (AUC = 0.950) and test cohorts (AUC = 0.942).

Conclusion

The constructed nomogram model could be a practical tool for predicting unfavorable functional outcomes in ischemic stroke patients underwent early rehabilitation after acute phase.

Hypertensive crisis: diagnosis, presentation, and treatment

PURPOSE OF REVIEW

Hypertensive crisis (HTN-C) is a condition of increasing prevalence. It carries significant morbidity and mortality, and prompt recognition and treatment are crucial. There is a paucity of controlled trials, so a working knowledge of the most recent literature in the area of HTN-C is helpful.

RECENT FINDINGS

Novel serological markers, including serum corin, have been found to aid in the early identification of end-organ damage from severely elevated blood pressure (BP). In the area of BP following thrombolysis for ischemic stroke, lower target BP (130-140 mmHg) is associated with some improved outcomes. Two large trials of lower BP following mechanical thrombectomy in stroke have failed to show improved outcomes; however, observed data show benefits at lower than currently recommended levels. Clevidipine, a calcium channel blocker marketed for unique use in HTN-C, was found to be noninferior to the generic less expensive nicardipine. Oral nifedipine was found to be the most effective agent for sustained BP reduction in preeclampsia.

SUMMARY

HTN-C remains an area with few prospective randomized trials, but there is active research on identifying lower goals for specific clinical scenarios. Ideal therapeutic agents should be tailored for specific end-organ damage.

The SON2A2 score: A novel grading scale for predicting hemorrhage and outcomes after thrombolysis

Objectives

This study aimed to develop a score including novel putative predictors for predicting the risk of sICH and outcomes after thrombolytic therapy with intravenous (IV) recombinant tissue-type plasminogen activator (r-tPA) in acute ischemic stroke patients.

Methods

All patients with acute ischemic stroke treated with IV r-tPA at three university-based hospitals in Chongqing, China, from 2014 to 2019 were retrospectively studied. Potential risk factors associated with sICH (NINDS criteria) were determined with multivariate logistic regression, and we developed our score according to the magnitude of logistic regression coefficients. The score was validated in another independent cohort. Area under the receiver operating characteristic curve (AUC-ROC) was used to assess the performance of the score. Calibration was evaluated using the Hosmer–Lemeshow goodness-of-fit method.

Results

The SON2A2 score (0 to 8 points) consisted of history of smoking (no = 1, yes = 0, β = 0.81), onset-to-needle time (≥3.5 = 1,&lt;3.5=0, β = 0.74), NIH Stroke Scale on admission (&gt;10 = 2, ≤10 = 0, β = 1.22), neutrophil percentage (≥80.0% = 1, &lt;80% = 0, β = 0.81), ASPECT score (≤11 = 2, &gt;11 = 0, β = 1.30), and age (&gt;65 years = 1, ≤65 years = 0, β = 0.89). The SON2A2 score was strongly associated with sICH (OR 1.98; 95%CI 1.675–2.34) and poor outcomes (OR 1.89; 95%CI 1.68–2.13). AUC-ROC in the derivation cohort was 0.82 (95%CI 0.77–0.86). Similar results were obtained in the validation cohort. The Hosmer–Lemeshow test revealed that predicted and observed event rates in derivation and validation cohorts were very close.

Conclusion

The SON2A2 score is a simple, efficient, quick, and easy-to-perform scale for predicting the risk of sICH and outcome after intravenous r-tPA thrombolysis within 4.5 h in patients with ischemic stroke, and risk assessment using this test has the potential for early and personalized management of this disease in high-risk patients.

Blood Pressure Goals in Acute Stroke

Antihypertensive treatment is highly effective in both primary and secondary prevention of stroke. However, current guideline recommendations on the blood pressure goals in acute stroke are clinically empirical and generally conservative. Antihypertensive treatment is only recommended for severe hypertension. Several recent observational studies showed that the relationship between blood pressure and unfavorable clinical outcomes was probably positive in acute hemorrhagic stroke but J- or U-shaped in acute ischemic stroke with undetermined nadir blood pressure. The results of randomized controlled trials are promising for blood pressure management in hemorrhagic stroke but less so in ischemic stroke. A systolic blood pressure goal of 140 mm Hg is probably appropriate for acute hemorrhagic stroke. The blood pressure goal in acute ischemic stroke, however, is uncertain, and probably depends on the time window of treatment and the use of revascularization therapy. Further research is required to investigate the potential benefit of antihypertensive treatment in acute stroke, especially with regard to the possible reduction of blood pressure variability and more intensive blood pressure lowering in the acute and subacute phases of a stroke, respectively.