Increased blood pressure variability following acute stroke is associated with poor long-term outcomes

Abstract Objective Our work aimed to investigate the association between vigorous physical activity and visit-to-visit systolic blood pressure variability (BPV). Methods We conducted a post hoc analysis of SPRINT (Systolic Blood Pressure Intervention Trial), a well-characterized cohort of participants randomized to intensive (<120 mmHg) or standard (<140 mmHg) SBP targets. We assessed whether patients with hypertension who habitually engage in vigorous physical activity would have lower visit-to-visit systolic BPV compared with those who do not engage in vigorous physical activity. Visit-to-visit systolic BPV was calculated by standard deviation (SD), average real variability (ARV), and standard deviation independent of the mean (SDIM) using measurements taken during the 1-, 2-, 3-, 6-, 9- and 12-month study visits. A medical history questionnaire assessed vigorous physical activity, which was divided into three categories according to the frequency of vigorous physical activity. Results A total of 7571 participants were eligible for analysis (34.8% female, mean age 67.9±9.3 years). During a follow-up of 1-year, vigorous physical activity could significantly reduce SD, ARV, and SDIM across increasing frequency of vigorous physical activity. There were negative linear trends between frequency of vigorous physical activity and visit-to-visit systolic BPV. Conclusions Long-term engagement in vigorous physical activity was associated with lower visit-to-visit systolic BPV.

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Twenty-four hour systolic blood pressure predicts long-term mortality following acute stroke

Journal of Hypertension ◽

10.1097/00004872-200112000-00003 ◽

2001 ◽

Vol 19 (12) ◽

pp. 2127-2134 ◽

Cited By ~ 57

Author(s):

Thompson G. Robinson ◽

Suzanne L. Dawson ◽

Usman Ahmed ◽

Brad Manktelow ◽

Martin D. Fotherby ◽

...

Keyword(s):

Blood Pressure ◽

Systolic Blood Pressure ◽

Acute Stroke ◽

Long Term Mortality

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Long-Term Outcomes of a Cluster-Randomized Trial Testing the Effects of Blood Pressure Telemonitoring and Pharmacist Management

Journal of Patient-Centered Research and Reviews ◽

10.17294/2330-0698.1506 ◽

2017 ◽

Vol 4 (3) ◽

pp. 166

Author(s):

Stephen Asche ◽

Anna Bergdall ◽

Steven Dehmer ◽

Beverly Green ◽

JoAnn Sperl-Hillen ◽

...

Keyword(s):

Blood Pressure ◽

Randomized Trial ◽

Cluster Randomized Trial ◽

Long Term Outcomes ◽

Trial Testing ◽

Cluster Randomized

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Dose-Response Relationship Between Long-Term Blood Pressure Variability and Cognitive Decline

Stroke ◽

10.1161/strokeaha.120.033697 ◽

2021 ◽

Author(s):

Chenglong Li ◽

Yanjun Ma ◽

Rong Hua ◽

Zhenchun Yang ◽

Baoliang Zhong ◽

...

Keyword(s):

Blood Pressure ◽

Cognitive Decline ◽

Dose Response ◽

Coefficient Of Variation ◽

Blood Pressure Variability ◽

Turning Point ◽

Linear Mixed Model ◽

Response Relationship ◽

Dose Response Relationship

Background and Purpose: We aimed to test whether higher long-term blood pressure variability was associated with accelerated rate of cognitive decline and evaluate potential dose-response relationship. Methods: Original survey data from the Health and Retirement Study and the English Longitudinal Study of Ageing were used. Standardized Z score of cognitive function was the main outcome measure. Visit-to-visit blood pressure SD, coefficient of variation, and variation independent of mean were used. Linear mixed model and restricted spline were applied to assess association and explore dose-response pattern. Segmented regression was used to analyze dose-response relationship and estimate turning point. Meta-analysis using random-effects model was conducted to pool results, with I 2 used to test heterogeneity. Results: A total of 12 298 dementia-free participants were included (mean age: 64.6±8.6 years). Significant association was observed between blood pressure variability and cognitive decline. Each 10% increment in coefficient of variation of systolic and diastolic blood pressure was associated with accelerated global cognitive decline of 0.026 SD/y (95% CI, 0.016–0.036, P< 0.001) and 0.022 SD/y (95% CI, 0.017–0.027, P< 0.001), respectively. Nonlinear dose-response relationship was found ( P< 0.001 for nonlinearity), with clear turning point observed ( P< 0.001 for change in slopes). Conclusions: Higher long-term blood pressure variability was associated with accelerated cognitive decline among general adults aged ≥50 years, with nonlinear dose-response relationship. Further randomized controlled trials are warranted to evaluate potential benefits of blood pressure variability-lowering strategies from a cognitive health perspective.

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Abstract WP245: Hyperacute Blood Pressure Variability is Associated with Early Neurological Deterioration

Stroke ◽

10.1161/str.48.suppl_1.wp245 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Joseph Kim ◽

Jeffrey L Saver ◽

David S Liebeskind ◽

Sidney Starkman ◽

Scott Hamilton ◽

...

Keyword(s):

Blood Pressure ◽

Emergency Department ◽

Cerebral Ischemia ◽

Acute Stroke ◽

Symptom Onset ◽

Blood Pressure Variability ◽

Final Diagnosis ◽

Controlled Study ◽

Double Blind ◽

Neurologic Deterioration

Background: Increased blood pressure variability (BPV) has been associated with worse outcomes in acute stroke. The effect of hyperacute (<4 hours) BPV on early neurologic deterioration (END) has not been described. Objective: To investigate whether BPV in the first hours after stroke onset is associated with END from prehospital evaluation to presentation at the emergency department Methods: All patients enrolled in the NIH Field Administration of Stroke Therapy-Magnesium (FAST-MAG) phase 3 trial were included. FAST-MAG was a multicenter, randomized, double-blind, placebo-controlled study looking at whether initiation of magnesium sulfate (20 grams/24 hours) in the prehospital setting of acute stroke would reduce disability. Study agent was initiated prior to hospital arrival < 2 hours from symptom onset. BPV was defined as the standard deviation of systolic blood pressure of all readings obtained by 4 hours after initiation of study agent. END was diagnosed as Glasgow Coma Scale (GCS) decrease by ≥ 2 points between the prehospital evaluation and post-emergency department arrival assessment by a study nurse. Results: There were 1,700 cases evaluated by paramedics 24 minutes (15-45 IQR), and by study nurses 150 minutes (120-180) after symptom onset with a median of 6 (IQR 5-6) BP readings. The mean (±SD) age was 69±13 years, 42.6% were women, and the median prehospital GCS was 15 (IQR 14-15). The final diagnosis was cerebral ischemia in 73.3% of patients, intracranial hemorrhage in 22.8%, and a stroke-mimicking condition in 3.9%. END was seen in 202 (12%) of subjects, with higher rates noted in those with intracerebral hemorrhage (ICH) compared to cerebral ischemia (31% vs 6%). Overall, there was greater BPV in patients with END (23mmHg vs 15mmHg, p<0.001). Blood pressure variability was greater in cases of cerebral ischemia with END (N=1,245, 18mmHg vs 15mmHg, p=0.004) and in ICH cases with END (N=387, 23mmHg vs 15mmHg, p<0.001). Conclusion: Greater blood pressure variability is associated with early neurologic deterioration in patients with cerebral ischemia and ICH evaluated <2 hours from symptom onset.

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Abstract 70: Importance of Both Self-consent and Proxy- consent Enrollments to Avoid Bias in Acute Stroke Randomized Trials

Stroke ◽

10.1161/str.48.suppl_1.70 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Kristina Shkirkova ◽

Nelson Wu ◽

Sidney Starkman ◽

Nerses Sanossain ◽

Scott Hamilton ◽

...

Keyword(s):

Informed Consent ◽

Acute Stroke ◽

Randomized Trials ◽

Proxy Consent ◽

Long Term Outcomes ◽

Stroke Population ◽

Acute Cerebral Ischemia ◽

Hemorrhage Volume ◽

Artery Disease

Background: Informed consent options for acute stroke randomized trials include self-consent from patients with retained competency, proxy consent from a legally authorized representative (LAR), and exception from informed consent in emergency circumstances (EFIC). Mechanisms other than self-consent trespass upon the ethical principle of autonomy (respect for persons), and should be used only if self-consent alone would bias the patient population. Methods: We analyzed acute stroke patients enrolled within 2h of symptom onset in the NIH Phase 3 Field Administration of Stroke Therapy - Magnesium (FAST-MAG) trial, comparing entry characteristics and outcomes with different consent mechanisms. Results: Among 1700 patients, median time from onset to study entry was 45 min (IQR 35-62). Overall, 60% of patients were competent and provided self-consent, 39% noncompetent and enrolled by proxy consent from an on-scene LAR, and 1% noncompetent enrolled using EFIC/delayed consent. Compared to self-consented patients, proxy-consented patients were: older, 73.8 vs 66.5, p<0.001; more often female, 47% vs 40%, p<0.02; and a higher frequency of several vascular risk factors, including hypertension, 81% vs 76%, p<0.05, diabetes, 26% vs20%, p<0.01, atrial fibrillation, 29% vs 17%, p<0.001, and coronary artery disease, 24% vs 19%, p<0.01. Proxy consent patients had more severe initial stroke deficits, prehospital LAMS, 4.1 vs 3.5, p<0.001. Proxy consent patients with acute cerebral ischemia had more advanced initial ischemic stroke lesions, ASPECTS 8.3 vs 9.3, p<0.001, and received tPA more often, 35% vs 20%, p<0.001. Proxy consent patients with intracerebral hemorrhage patient had larger initial hemorrhage volume (cc), 42.2 vs 22.6, p<0.001. Proxy consent patients had worse final outcomes, with freedom from disability (mRS 0-1) at 90d, 23.6% vs 44.3%, p<0.001. Conclusions: Proxy-informed consent patients differ systematically from self-consent patients, with older age, more comorbidities, more severe deficits, and worse long term outcomes. To ensure that acute stroke trial cohorts are representative of the general stroke population, it is important that enrollment mechanisms include proxy and/or deferred consent.

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Abstract 15439: Lesion Complexity and Long-term Outcomes According to Mean Observed Blood Pressure After Percutaneous Coronary Intervention

Circulation ◽

10.1161/circ.142.suppl_3.15439 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Jong Il Park ◽

Byung Jun Kim ◽

Hun Tae Kim ◽

Jung Hee Lee ◽

Ung Kim ◽

...

Keyword(s):

Blood Pressure ◽

Percutaneous Coronary Intervention ◽

Independent Predictor ◽

Coronary Intervention ◽

Long Term Outcomes ◽

Percutaneous Coronary ◽

Group A ◽

Group B ◽

Group D

Background: The guideline recommended strict blood pressure (BP) control for the patients treated with percutaneous coronary intervention (PCI). We aimed to evaluate the relationship between mean observed BP and long-term outcomes for patients with or without lesion complexity. Methods: A total of 1,470 patients who underwent PCI were investigated. We categorized the study population into four groups based on mean observed BP and lesion complexity (left main & three-vessel disease, chronic total occlusion, total stent length ≥60mm, or bifurcation two stenting): Group A (non-complex & systolic BP ≤120mmHg, n=310), Group B (non-complex & systolic BP >120mmHg, n=674), Group C (complex & systolic BP ≤120mmHg, n=131), and Group D (complex & systolic BP >120mmHg, n=355). We evaluated major adverse cardiovascular and cerebrovascular events (MACCEs), defined as cardiac death, myocardial infarction (MI), repeat target vessel revascularization, or stroke. Results: Well-controlled BP group (Group A&C) showed significantly lower systolic BP than uncontrolled BP group (Group B&D) (114.3±6.1mmHg vs. 130.7±7.6mmHg, p<0.001). MACCEs occurred less frequently in Group A (18.9%) than Group B (23.6%), Group C (22.7%), and Group D (33.6%) (p=0.001) at 8 years. After multivariate analysis, with Group A as a reference, the adjusted hazard ratio (HR) for MACCEs was 1.382 (95% confidence interval [CI] 0.978-1.954, p=0.067) for Group B, 1.559 (95% CI 0.957-2.540, p=0.075) for Group C, and 1.872 (95% CI 1.296-2.705, p=0.001) for Group D. In Cox regression model, although lesion complexity was not associated with MACCE, systolic BP≤120mmHg was an independent predictor for reduced rate of MACCE (HR 0.667, 95% CI 0.485-0.918, p=0.013). Conclusions: Mean observed systolic BP ≤120mmHg after PCI was independent predictor for reduced MACCEs regardless of lesion complexity. Key Words: Blood Pressure; Percutaneous Coronary Intervention; Lesion Complexity; Treatment Outcome

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Abstract P120: Association Of Liver Transaminase Levels And Long-term Blood Pressure Variability In Military Young Males In Taiwan

Hypertension ◽

10.1161/hyp.76.suppl_1.p120 ◽

2020 ◽

Vol 76 (Suppl_1) ◽

Author(s):

Gen-min Lin ◽

Pang-yen Liu

Keyword(s):

Blood Pressure ◽

Lower Risk ◽

Blood Pressure Variability ◽

Smoking Status ◽

Linear Regression Analysis ◽

Elevated Serum ◽

Young Male ◽

Liver Transaminase ◽

Young Males

Background: Elevated serum liver transaminases (AST and ALT), highly related to metabolic disorders, are paradoxically associated with lower risk of cardiovascular disease (CVD) and mortality. Blood pressure variability (BPV), a risk factor of CVD, has not been examined the relationship with serum liver transaminase. Methods: A prospective cohort of 1,112 military males, aged 32.2 years was collected in Taiwan. Serum AST and ALT were obtained from a 12 hour-fast blood sample of each participant. BPV was assessed by standard deviation (SD) and average real variability (ARV) of systolic and diastolic blood pressure (SBP and DBP), respectively across 4 visits during the study period (2012-14, 2014-15, 2015-16, and 2016-18). Multivariable linear regression analysis was used to determine the association adjusting for age, body mass index, SBP, DBP, lipid profiles, physical activity, alcohol and smoking status. Results: In the unadjusted model, serum ALT were positively correlated with SD DBP and ARV DBP (β (SE) =0.36 (0.16) and 0.24 (0.12), respectively), and so were AST (β= 0.19 (0.08) and 0.14 (0.06), respectively). However, all the associations were insignificant with adjustments. By contrast, the associations with systolic BPV were initially insignificant in the unadjusted model. With adjustments, serum ALT were negatively correlated with SD SBP and ARV SBP (β= -0.34 (0.16) and -0.24 (0.12), respectively) and so were AST (β= -0.14 (0.07) and -0.11 (0.06), respectively). Conclusion: Our findings suggest that liver transaminase levels were negatively correlated with long-term systolic BPV in young male adults, possibly accounting for the lower risk of CVD in previous studies.

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