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

Stroke ◽  
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.

Abstract TP234: The Effect of Early Treatment with Magnesium on Blood Pressure Variability in Hyperacute Stroke

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Joseph Kim ◽  
Jeffrey L Saver ◽  
David S Liebeskind ◽  
Sidney Starkman ◽  
Scott Hamilton ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Standard Deviation ◽  
Cerebral Ischemia ◽  
Intracerebral Hemorrhage ◽  
Systolic Blood Pressure ◽  
Acute Stroke ◽  
Magnesium Sulfate ◽  
Blood Pressure Variability ◽  
Hyperacute Stroke ◽  
Magnesium Treatment

Background: Increased blood pressure (BP) variability has been associated with worse outcomes in acute stroke. Magnesium has been shown to have both vasoactive and cardio-active properties that could potentially attenuate blood pressure variability emergently. Objective: To investigate whether intravenous magnesium sulfate can minimize blood pressure variability in hyperacute stroke. Methods: All patients with a diagnosis of stroke (cerebral ischemia, intracerebral hemorrhage) 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. Blood pressure variability was defined as the standard deviation (SD) of systolic blood pressure of all readings obtained by 4 hours after initiation of study agent. BP variability was compared using t-test of the bootstrapped SD between groups. Results: In total, 1,700 patients were included in the study with a median of 6 (IQR 5-6) BP readings, of which 1,245 had cerebral ischemia (CI), 387 had intracerebral hemorrhage (ICH), and 68 had stroke mimics. Of those with CI, 632 received magnesium and 613 placebo; the standard deviation of systolic blood pressure was not significantly different between those who received magnesium and those who did not (14.9mmHg vs. 15.3mmHg, p=0.315). In the ICH population (195 magnesium, 192 placebo), magnesium treatment also did not affect BP variability (22.5mmHg vs. 21.1mmHg, p=0.197). For the overall study group, hyperacute magnesium treatment had no effect on blood pressure variability (16.7mmHg vs. 16.6mmHg, p=.907). Conclusion: Treatment with magnesium did not reduce BP variability in hyperacute stroke.

Abstract TP41: Prevalence and Factors Associated with Early Ischemic Changes on Non-contrast CT Obtained Less Than 90 Minutes After Symptom Onset

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Jared Noroozi ◽  
David S Liebeskind ◽  
Jeffrey L Saver ◽  
Sidney Starkman ◽  
Juan Pablo Villablanca ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Cerebral Ischemia ◽  
Symptom Onset ◽  
Clinical Information ◽  
Final Diagnosis ◽  
Factors Associated ◽  
History Of ◽  
Artery Disease ◽  
Initial Imaging ◽  
Contrast Ct

Background: Usually early infarct signs on imaging take a few hours to develop in ischemic stroke. There may be a subset of patients manifesting early infarct signs on imaging hyperacutely. Objective: To determine the prevalence and factors associated with very early infarct signs on ASPECTS among patients with cerebral ischemia who were imaged <90 minutes after symptom onset. Methods: Subjects participating in the NIH Field Administration of Stroke Therapy- Magnesium (FAST-MAG) phase 3 clinical trial with a final diagnosis of cerebral ischemia (TIA or Stroke) and initial imaging performed <90 minutes from last known well time (LKWT) were included. ASPECTS was graded by a neuroradiologist (JPV) blinded to all clinical information. Individual subjects were characterized as having no early ischemic changes (ASPECTS 10) vs. early ischemic changes (ASPECTS 0-9). We describe the prevalence of early ischemic signs in this prospectively enrolled cohort, clinical factors associated with early ischemic changes as well as outcomes. Results: There were 566 cases imaged a mean of 71 (SD 11) minutes after LKWT. Mean age was 69 (SD 13), 43% women, 93% ischemic stroke, 7% TIA, median emergency department NIHSS 8 (IQR 3-16), median ASPECTS score of 10 (IQR 7-10, range 1-10). There were 200 cases with early ischemic findings (35%). Early ischemic changes were not related to age, blood pressure, history of hypertension, diabetes, dyslipidemia, coronary artery disease, or time to imaging (71 vs. 71 mins). Early ischemic changes were more commonly noted in women (50% vs. 39%, p=0.015) and associated higher presenting NIHSS (14 [IQR 7-20] vs 5 [IQR 2-11], p<0.001). The presence of any hyperacute ischemia change was associate with worse 90-day outcome (modified Rankin score 3 [IQR 1-5] vs 1 [IQR 0-3, p<0.001). Conclusions: Early ischemic changes were noted on about 1/3 rd of imaging obtained <90 minutes after symptom onset. The presence of hyperacute ischemic changes is associated with more severe stroke and poor clinical outcomes.

scholarly journals Carbidopa for Afferent Baroreflex Failure in Familial Dysautonomia

Hypertension ◽  
2020 ◽  
Vol 76 (3) ◽  
pp. 724-731
Author(s):  
Lucy Norcliffe-Kaufmann ◽  
Jose-Alberto Palma ◽  
Jose Martinez ◽  
Horacio Kaufmann
Keyword(s):  
Blood Pressure ◽  
Blood Pressure Variability ◽  
Low Dose ◽  
Familial Dysautonomia ◽  
Reduce Blood Pressure ◽  
Catecholamine Release ◽  
High Dose ◽  
Double Blind ◽  
Adequate Treatment ◽  
Baroreflex Failure

Afferent lesions of the arterial baroreflex occur in familial dysautonomia. This leads to excessive blood pressure variability with falls and frequent surges that damage the organs. These hypertensive surges are the result of excess peripheral catecholamine release and have no adequate treatment. Carbidopa is a selective DOPA-decarboxylase inhibitor that suppresses catecholamines production outside the brain. To learn whether carbidopa can inhibit catecholamine-induced hypertensive surges in patients with severe afferent baroreflex failure, we conducted a double-blind randomized crossover trial in which patients with familial dysautonomia received high dose carbidopa (600 mg/day), low-dose carbidopa (300 mg/day), or matching placebo in 3 4-week treatment periods. Among the 22 patients enrolled (13 females/8 males), the median age was 26 (range, 12–59 years). At enrollment, patients had hypertensive peaks to 164/116 (range, 144/92 to 213/150 mm Hg). Twenty-four hour urinary norepinephrine excretion, a marker of peripheral catecholamine release, was significantly suppressed on both high dose and low dose carbidopa, compared with placebo ( P =0.0075). The 2 co-primary end points of the trial were met. The SD of systolic BP variability was reduced at both carbidopa doses (low dose: 17±4; high dose: 18±5 mm Hg) compared with placebo (23±7 mm Hg; P =0.0013), and there was a significant reduction in the systolic BP peaks on active treatment ( P =0.0015). High- and low-dose carbidopa were similarly effective and well tolerated. This study provides class Ib evidence that carbidopa can reduce blood pressure variability in patients with congenital afferent baroreflex failure. Similar beneficial effects are observed in patients with acquired baroreflex lesions.

scholarly journals Increasing Blood Pressure Variability Predicts Poor Functional Outcome Following Acute Stroke

2021 ◽  
Vol 30 (1) ◽  
pp. 105466
Author(s):  
Karen OB Appiah ◽  
Mintu Nath ◽  
Lisa Manning ◽  
William J Davison ◽  
Sara Mazzucco ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Acute Stroke ◽  
Functional Outcome ◽  
Blood Pressure Variability ◽  
Poor Functional Outcome

scholarly journals Rice Bran Supplement Containing A Functional Substance, the Novel Peptide Leu-Arg-Ala, has Anti-Hypertensive Effects: A Double-Blind, Randomized, Placebo-Controlled Study

Nutrients ◽  
2019 ◽  
Vol 11 (4) ◽  
pp. 726
Author(s):  
Ogawa ◽  
Shobako ◽  
Fukuhara ◽  
Satoh ◽  
Kobayashi ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Placebo Group ◽  
Adverse Events ◽  
Rice Bran ◽  
Test Group ◽  
Normal Blood ◽  
Controlled Study ◽  
The Novel ◽  
Normal Blood Pressure ◽  
Double Blind

The anti-hypertensive effect of processed rice bran (PRB) was recently reported, for which the novel peptide Leu-Arg-Ala (LRA) was identified as the functional substance. The purpose of this study was to assess the anti-hypertensive effects of a rice bran supplement containing PRB in individuals with high-normal blood pressure (systolic blood pressure (SBP): 130–139 mmHg and/or diastolic blood pressure (DBP): 85–89 mmHg) or grade 1 hypertension (SBP: 140–159 mmHg and/or DBP: 90–99 mmHg). One hundred individuals with high-normal blood pressure or grade 1 hypertension were recruited to participate in this double-blind, randomized, placebo-controlled study. Participants were randomly allocated to the placebo group (n = 50) or the test group (n = 50). Each group took four test tablets (43 μg LRA/day) or four placebo tablets daily. The decrease in blood pressure in the test group compared with the placebo group was the primary outcome. Adverse events were recorded and hematological/urinary parameters measured to determine the safety of the supplement, which was the secondary outcome. In total, 87 participants completed the study. The SBP of the test group at 12 weeks was significantly lower than that of the placebo group (p = 0.0497). No serious adverse events were observed. Daily consumption of a rice bran supplement containing PRB can safely improve mildly elevated blood pressure.

scholarly journals The influence of the infusion of ephedrine and phenylephrine on the hemodynamic stability after subarachnoid anesthesia in senior adults - a controlled randomized trial

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Miodrag Žunić ◽  
Nevenka Krčevski Škvarč ◽  
Mirt Kamenik
Keyword(s):  
Blood Pressure ◽  
Final Analysis ◽  
Controlled Study ◽  
Senior Adults ◽  
Hemodynamic Changes ◽  
Hemodynamic Stability ◽  
Double Blind ◽  
Registration Number ◽  
Phenylephrine Infusion ◽  
Orthopedic Patients

Abstract Background We studied the influence of ephedrine or phenylephrine infusion administered immediately after spinal anesthesia (SA) on hemodynamics in elderly orthopedic patients. Methods A prospective, randomized, double-blind, placebo-controlled study. After a subarachnoid injection of 15 mg of levobupivacaine, the participants received an infusion of either ephedrine 20 mg (E group), phenylephrine 250 mcg (P group) or saline (C group) within 30 min. We measured blood pressure, cardiac index (CI) and heart rate (HR) from 15 min before to 30 min after SA. Results Seventy patients were included in the final analysis. At the end of measurements, mean arterial pressure (MAP) decreased significantly after SA in comparison to the baseline value in the C group but was maintained in the P and E group, with no significant differences between the groups. CI decreased after SA in the C group, was maintained in the P group, and increased significantly in the E group with significant differences between the C and E group (p = 0.049) also between the P and E (p = 0.01) group at the end of measurements. HR decreased significantly after SA in the C and P group but was maintained in the E group, with significant differences between the P and E group (p = 0.033) at the end of measurements. Conclusions Hemodynamic changes after SA in elderly orthopedic patients can be prevented by an immediate infusion of phenylephrine or ephedrine. In addition to maintaining blood pressure, the ephedrine infusion also maintains HR and increases CI after SA. Trial registration ISRCTN registry with registration number ISRCTN44377602, retrospectively registered on 15 June 2017.

A Double-Blind Comparison of Granisetron and Placebo for the Treatment of Acute Migraine in The Emergency Department

Cephalalgia ◽  
1991 ◽  
Vol 11 (5) ◽  
pp. 207-213 ◽  
Author(s):  
Bruce MT Rowat ◽  
Charles F Merrill ◽  
Alan Davis ◽  
Valerie South
Keyword(s):  
Emergency Department ◽  
Controlled Study ◽  
Acute Migraine ◽  
Eligibility Criteria ◽  
Double Blind ◽  
Post Infusion ◽  
Affective Components ◽  
Headache Pain ◽  
Blind Comparison ◽  
Categorical Scale

Three hundred and ninety-seven patients who presented to the emergency department were screened for a randomized, double-blind, placebo-controlled study of iv granisetron (40 μg/kg or 80 μg/kg) in acute migraine. Twenty-eight patients fulfilled the stringent eligibility criteria and completed the study. Rescue medication was required 2 h post-infusion in 8 of 10 patients receiving granisetron 40 μg/kg, 5 of 10 patients receiving granisetron 80 μg/kg, and 6 of 8 patients receiving placebo. Significant improvement (p < 0.05) in headache pain (on a visual analogue scale and categorical scale) was observed in the 80–μg/kg group. Headache pain evaluated with the Hunter headache scale indicated improvement for the sensory and affective components of headache pain in both granisetron groups. Except for more nausea at 30 min in the placebo group, no significant differences were noted between treatments. All three treatments were well tolerated. Granisetron may be effective for acute migraine headache; however, further studies with increased patient numbers are required.

scholarly journals Optic nerve head edema among patients presenting to the emergency department

Neurology ◽  
2018 ◽  
Vol 90 (5) ◽  
pp. e373-e379 ◽  
Author(s):  
Virender Sachdeva ◽  
Caroline Vasseneix ◽  
Rabih Hage ◽  
Samuel Bidot ◽  
Lindsay C. Clough ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Emergency Department ◽  
Logistic Regression ◽  
Visual Loss ◽  
Final Diagnosis ◽  
Neurologic Deficit ◽  
Elevated Blood Pressure ◽  
Fundus Photography ◽  
Elevated Blood ◽  
Patient Disposition

ObjectiveTo determine the frequency of and predictive factors for optic nerve head edema (ONHE) among patients with headache, neurologic deficit, visual loss, or elevated blood pressure in the emergency department (ED).MethodsCross-sectional analysis was done of patients with ONHE in the prospective Fundus Photography vs Ophthalmoscopy Trial Outcomes in the Emergency Department (FOTO-ED) study. Demographics, neuroimaging results, management, and patient disposition were collected. Patients in the ONHE and non-ONHE groups were compared with bivariate and logistic regression analyses.ResultsOf 1,408 patients included, 37 (2.6%, 95% confidence interval 1.9–3.6) had ONHE (median age 31 [interquartile range 26–40] years, women 27 [73%], black 28 [76%]). ONHE was bilateral in 27 of 37 (73%). Presenting complaints were headache (18 of 37), visual loss (10 of 37), acute neurologic deficit (4 of 37), elevated blood pressure (2 of 37), and multiple (3 of 37). The most common final diagnoses were idiopathic intracranial hypertension (19 of 37), CSF shunt malfunction/infection (3 of 37), and optic neuritis (3 of 37). Multivariable logistic regression found that body mass index ≥35 kg/m2 (odds ratio [OR] 1.9, p = 0.0002), younger age (OR 0.5 per 10-year increase, p < 0.0001), and visual loss (OR 5, p = 0.0002) were associated with ONHE. Patients with ONHE were more likely to be admitted (62% vs 19%), to be referred to other specialists (100% vs 54%), and to receive neuroimaging (89% vs 63%) than patients without ONHE (p < 0.001). Fundus photographs in the ED allowed initial diagnosis of ONHE for 21 of 37 (57%) patients. Detection of ONHE on ED fundus photography changed the final diagnosis for 10 patients.ConclusionsOne in 38 patients (2.6%) presenting to the ED with a chief complaint of headache, neurologic deficit, visual loss, or elevated blood pressure had ONHE. Identification of ONHE altered patient disposition and contributed to the final diagnosis, confirming the importance of funduscopic examination in the ED.

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