Blood pressure variability in subacute stage and risk of major vascular events in ischemic stroke survivors

Objectives: We recently reported that blood pressure variability (BPV) during a subacute stage of ischemic stroke may affect functional outcome. This study aimed to test a hypothesis whether subacute BPV increases a risk of subsequent vascular events following acute ischemic stroke. Methods: From a prospective stroke registry database, consecutive ischemic stroke patients hospitalized within 48 h of onset were identified. Subacute BPV parameters were defined as maximum 2 -minimum, standard deviation (SD) and coefficient of variation (CV) of systolic BP (SBP) from 72 hours after onset to discharge. Primary outcome was a time to a subsequent vascular event (SVE), which was a composite of stroke, myocardial infarction and other vascular death. The BPV parameters were categorized into tertiles and dose-response relationships between BPV parameters and SVE were examined. The hazard ratios (HRs) of BPV parameters were estimated using Cox proportional hazard models with adjustments for predetermined confounders. Result: Of 3047 patients (mean age, 66.4 years and median NIHSS score, 3); BP was measured by median 46 times per person during the subacute stage (median 7 days). Median follow-up duration was 352 days (interquartile range, 112 to 389 days) and cumulative SVE rates were 7.0%. SVE rates differed by the tertiles of BPV parameters; SVE rates of lower, middle and upper thirds of maximum-minimum were 5.2%, 6.4% and 9.6%, those of SD were 5.4%, 8.5% and 7.9% and those of CV were 4.9%, 8.4% and 7.6%, respectively (P’s < 0.05 on log rank test). There were significant dose-response relationships of SVE with maximum-minimum and SD (P < 0.01 and 0.01), not with CV (P = 0.14) independent of mean SBP, age, sex, history of stroke, hypertension, diabetes mellitus, hyperlipidemia, atrial fibrillation and stroke subtypes. Adjusted HRs of one-SD of maximum-minimum, SD and CV of SBP were 1.24 (95% confidence interval, 1.09-1.40), 1.16 (1.01-1.32) and 1.15 (1.01-1.30), respectively. Conclusion: This study suggests that the increase of blood pressure variability at subacute stage of ischemic stroke may increase the risk of subsequent vascular events.

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SYSTOLIC BLOOD PRESSURE VARIABILITY DURING MECHANICAL THROMBECTOMY IS ASSOCIATED WITH EARLY NEUROLOGICAL DETERIORATION IN ACUTE ISCHEMIC STROKE PATIENTS

10.26226/morressier.58e389aed462b80292385662 ◽

2017 ◽

Author(s):

João Pedro Marto

Keyword(s):

Blood Pressure ◽

Ischemic Stroke ◽

Systolic Blood Pressure ◽

Acute Ischemic Stroke ◽

Blood Pressure Variability ◽

Mechanical Thrombectomy ◽

Neurological Deterioration ◽

Stroke Patients ◽

Early Neurological Deterioration ◽

Systolic Blood Pressure Variability

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Abstract 16967: Increased Blood Pressure Variability is Associated With Worse Outcome in Acute Ischemic Stroke

Circulation ◽

10.1161/circ.132.suppl_3.16967 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Adam de Havenon ◽

Haimei Wang ◽

Greg Stoddard ◽

Lee Chung ◽

Jennifer Majersik

Keyword(s):

Blood Pressure ◽

Logistic Regression ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Blood Pressure Variability ◽

Harmful Effect ◽

Final Analysis ◽

Ordinal Logistic Regression ◽

Stroke Severity ◽

The Mean

Background: Increased blood pressure variability (BPV) is detrimental in the weeks to months after ischemic stroke, but it has not been adequately studied in the acute phase. We hypothesized that increased BPV in acute ischemic stroke (AIS) patients would be associated with worse outcome. Methods: We retrospectively reviewed inpatients at our hospital between 2010-2014 with an ICD-9 code of AIS; 213 were confirmed to have AIS by a vascular neurologist. A modified Rankin Score (mRS) after discharge was available in 148/213, at a mean of 86 ± 60 days. In 45/213 the discharge mRS was either 0 or 6, in which case they were included in the final analysis. BPV was measured as the standard deviation (SD) of each patient’s systolic blood pressure readings during the first 24 hours and 5 days of hospitalization (9,844 total readings), or until discharge if discharged in <5 days (Figure 1). The SBP SD was further divided in quartiles. A multivariate ordinal logistic regression with the outcome of mRS, the primary predictor of quartiles of SBP SD, and baseline NIH stroke scale (NIHSS) to control for initial stroke severity. Results: Mean±SD age was 64.2 ± 16.3 years, NIHSS was 12.6 ± 7.9, and mRS was 2.7 ± 2.1. The mean SBP SDs for the first 24 hours and 5 days were 12.1 ± 6.2 mm Hg and 14.1 ± 4.9 mm Hg. In the ordinal logistic regression model, the quartiles of SBP SD for the first 24 hours and 5 days were positively associated with higher mRS (OR = 1.37, 95% CI 1.01 - 1.74, p = 0.009; OR = 1.30, 95% CI 1.03 - 1.63, p = 0.028). This effect became even more pronounced in patients with the highest quartile of variability (OR = 2.76, 95% CI 1.29 - 5.88, p = 0.009; OR = 2.10, 95% CI 1.01 - 4.36, p = 0.046). Conclusion: In our cohort of 193 patients with AIS, there was a significant association between increased systolic BPV and worse functional outcome, after controlling for initial stroke severity. This data suggests that increased BPV may have a harmful effect for AIS patients, which warrants a prospective observational study.

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Abstract 69: Distinct Grouping of Systolic Blood Pressure Trajectories During the First 24 Hours After Stroke Admission and Their Outcomes

Stroke ◽

10.1161/str.48.suppl_1.69 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Beom Joon Kim ◽

Moon-Ku Han ◽

Yong-Jin Cho ◽

Keun-Sik Hong ◽

Jun Lee ◽

...

Keyword(s):

Blood Pressure ◽

Ischemic Stroke ◽

Systolic Blood Pressure ◽

Age At Onset ◽

Stroke Patients ◽

Vascular Events ◽

Group 4 ◽

Group 3 ◽

Group 2 ◽

Group 1

Background: Blood pressure of ischemic stroke patients is a potentially modifiable clinical prognostic factor during acute period. However, BP changes dynamically over time and its temporal variation during acute stage has not received much attention. Methods: From a total of 3795 acute ischemic stroke patients who arrived within 24 hours after onset, we selected 2723 eligible patients who had more than 5 systolic blood pressure (SBP) measurements during 24 hours after arrival. To predict group SBPs for 8 time-points during the first 24 hours, a measured SBP reading was imputed to the nearest missing point. Trajectory grouping of acute stroke patients was estimated using PROC TRAJ, with delta BIC and prespecified modeling parameters. Early neurological deterioration (END) was captured during admission and recurrent vascular events was collected through a structured telephone interview at 1 years after. Results: Of the included cases, mean age at onset was 68 ± 13 year-old. NIHSS score at arrival was median 4 [2, 10] and recanalization treatment was done in 598 (22%). Hypertension was diagnosed in 1930 (71%). Based on 48,445 SBP readings during the first 24 hours after arrival, stroke cases were grouped into 5 distinct SBP trajectories as shown in the Figure: Group 1 (low BP), 17%; Group 2 (stable BP), 41%; Group 3 (rapidly stabilized SBP), 11%; Group 4 (higher SBP), 23%; Group 5 (extremely high SBP without stabilization), 8%. Trajectory grouping was independently associated with END and recurrent vascular events (see Figure). Group 1 had low odds of having END (adjusted OR [95% CI]; 0.62 [0.44-0.87], but Group 4 and 5 showed higher probability of having END (1.34 [1.04-1.73] and 1.76 [1.22-2.51]) and recurrent vascular events until 1 year (1.28 [1.00-1.64] and 1.82 [1.29-2.55]). However, Group 3 had comparable risks with Group 2. Conclusion: It was documented that SBP may successfully grouped into distinct trajectories, which are associated with outcomes after stroke.

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Abstract 65: Effects of Immediate Blood Pressure Reduction on Two-Year Mortality and Major Disability in Patients With Acute Ischemic Stroke

Stroke ◽

10.1161/str.48.suppl_1.65 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Jiang He ◽

Yonghong Zhang ◽

Tan Xu ◽

Dali Wang ◽

Chung-Shiuan Chen ◽

...

Keyword(s):

Blood Pressure ◽

Ischemic Stroke ◽

Treatment Group ◽

Acute Ischemic Stroke ◽

Antihypertensive Treatment ◽

Blood Pressure Reduction ◽

Control Group ◽

Antihypertensive Medications ◽

Vascular Events

Although elevated blood pressure (BP) is very common in patients with acute ischemic stroke, the management of hypertension among them remains controversial. We tested the effect of immediate BP reduction on two-year mortality and major disability in acute ischemic stroke patients. The China Antihypertensive Trial in Acute Ischemic Stroke, a randomized, single-blind, blinded end-points trial, was conducted in 4,071 patients with ischemic stroke within 48 hours of onset and elevated systolic BP (SBP). Patients were randomly assigned to receive antihypertensive treatment (n=2,038) or to discontinue all antihypertensive medications (n=2,033) during hospitalization. Post-treatment follow-ups were conducted at 3, 12, and 24 months after hospital discharge. The primary outcome was a composite of death and major disability at the two-year follow-up visit. Mean SBP was reduced by 21.8 in the treatment group and 12.7 mm Hg in the control group within 24 hours after randomization (P<0.001). Mean SBP was 137.3 mm Hg in the treatment group and 146.5 in the control group at day 7 after randomization (P<0.001). At two-year follow-up, study outcomes were obtained in 1945 (95.4%) participants in the treatment group and 1925 (94.7%) in the control group. 78.8% of the patients in the treatment group and 72.6% in the control group reported the use of antihypertensive medications (p<0.001). SBP was 138.8 mmHg in the antihypertensive treatment group and 139.7 in the control group (p=0.02). Among patients in the antihypertensive treatment group, 24.5% (476/1945) died or had a major disability, compared with 22.1% (425/1925) in the control group (odds ratio 1.14 [95% CI 0.99 to 1.33], p=0.078). Hazard ratios for all-cause mortality (1.01 [0.81, 1.25], p=0.95), recurrent stroke (0.91 [0.73, 1.13], p=0.40), and vascular events (0.97 [0.79, 1.19], p=0.76) were not statistically significant comparing the antihypertensive treatment group to the control group. The effect of antihypertensive treatment did not differ by pre-defined subgroups. In conclusion, among patients with acute ischemic stroke, BP reduction with antihypertensive medications during hospitalization did not reduce or increase the composite outcome of death and major disability over two years.

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