Abstract P440: Inpatient Blood Pressure Variability is Associated With Mortality and Poor Functional Outcome in Patients With Intracerebral Hemorrhage

Introduction: Although elevated blood pressure (BP) is an established risk factor for intracerebral hemorrhage (ICH), the impact of acute BP fluctuations on ICH outcomes remains unclear. In this study, we sought to investigate the effect of acute BP variability (BPV) on mortality and functional outcome in ICH survivors. Methods: Subjects were consecutive ICH patients ≥ 18 years with available inpatient BP data, who survived hospitalization. Four measures of systolic BPV were calculated: standard deviation (SD), coefficient of variation (CoV), average real variability (ARV), and successive variation (SV). Our outcomes were (1) death and (2) poor functional outcome, defined as a modified Rankin Score (mRS) of 3-6 in a period between 60-120 days after discharge. We assessed the effect of hyperacute (ICH event-72 hours) and acute/subacute (72 hours-discharge) BPV on outcomes. We constructed Cox proportional hazards and logistic regression models to investigate the associations of BPV (per 10 mmHg increase) with mortality and poor functional outcome, respectively, after adjustment for potential confounders. Results: We included 345 patients, 120 of whom had available mRS data. 151 (43.8%) patients were female and 280 (81.2%) were white; mean age was 71 (±13) years. SBP ARV and SBP SV were the strongest predictors of mortality (HR 2.53-2.91 per 10 mmHg increase), while SBP SD, CoV, and SV were the strongest predictors of poor functional outcome (OR 2.89-5.14 per 10 mmHg increase) (Table) . These associations remained significant when analyzing both hyperacute as well as acute/subacute BPV. Compared to hyperacute BPV, acute/subacute BPV was more strongly associated with both mortality and poor functional outcome. Conclusion: Inpatient blood pressure variability is an important determinant of mortality and poor functional outcome in ICH survivors. Further studies are needed to investigate the role of addressing BPV as a potential target for intervention.

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Abstract P160: Long-term Blood Pressure Variability And Cognitive Decline And Dementia Among Community-dwelling Elderly

Hypertension ◽

10.1161/hyp.76.suppl_1.p160 ◽

2020 ◽

Vol 76 (Suppl_1) ◽

Author(s):

Michael E Ernst ◽

Joanne Ryan ◽

Enayet K Chowdhury ◽

Anne M Murray ◽

Robyn L Woods ◽

...

Keyword(s):

Blood Pressure ◽

Cognitive Decline ◽

Blood Pressure Variability ◽

Proportional Hazards ◽

Cox Proportional Hazards ◽

Community Dwelling ◽

Immortal Time Bias ◽

Incident Dementia ◽

The Impact

Greater blood pressure variability (BPV) in midlife increases the risk of dementia, but the impact of BPV in cognitively intact older adults is unknown. We examined the risk of incident dementia and cognitive decline associated with long-term, visit-to-visit BPV in participants of the ASPirin in Reducing Events in the Elderly (ASPREE) study, a randomized primary prevention trial of daily low-dose aspirin in community-dwelling adults in Australia and the US aged 70 and older (65 if US minority), who were free of dementia or evidence of cognitive impairment at enrollment. The mean of three BPs using an automated cuff was recorded at baseline and annually; participants also underwent baseline and biennial standardized assessments of global cognition, delayed episodic memory, verbal fluency, processing speed and attention. Cognitive decline was pre-specified as a >1.5 standard deviation (SD) decline in score from baseline on any of the cognitive tests, while incident dementia was a pre-specified secondary endpoint of ASPREE which was adjudicated using DSM-IV criteria. BPV was estimated using within-individual SD of mean systolic BP across baseline and the first two annual visits, and participants with cognitive decline or incident dementia during this period were excluded from the analysis to avoid immortal time bias. After adjustment for key covariates, Cox proportional hazards regression revealed increased risks for dementia and cognitive decline during follow-up for individuals in the highest SD tertile of BPV (Table). Our findings suggest that high BPV in older ages should be considered a potential therapeutic target to preserve cognitive function.

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Abstract 16476: Visit-to-Visit Blood Pressure Variability is Associated With Incident Frailty: The Multidomain Alzheimer Preventive Trial (MAPT)

Circulation ◽

10.1161/circ.142.suppl_3.16476 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Laure Rouch ◽

Philipe de Souto Barreto ◽

Olivier Hanon ◽

Jacques Amar ◽

Yves Rolland ◽

...

Keyword(s):

Blood Pressure ◽

Standard Deviation ◽

Blood Pressure Variability ◽

Proportional Hazards ◽

Antihypertensive Drugs ◽

Cox Proportional Hazards ◽

Community Dwelling ◽

Clinical Predictors ◽

Increased Risk ◽

Preventive Trial

Introduction: Visit-to-visit blood pressure variability (BPV) has been associated with greater cardiovascular and all-cause mortality, cognitive impairment, and incident dementia. It may also represent a decline in homeostatic mechanisms in blood pressure (BP) regulation associated with frailty, one of the most problematic expression of population aging. Hypothesis: We hypothesized that visit-to-visit systolic (SBPV), diastolic (DBPV), mean arterial (MAPV) and pulse pressure (PPV) variability are associated with greater incident frailty. Methods: We included 1,394 non-frail community-dwelling participants aged ≥ 70 years from the Multidomain Alzheimer Preventive Trial (MAPT) who underwent repeated clinical examinations over a 5-year follow-up period. SBPV, DBPV, MAPV and PPV were evaluated using standard deviation, coefficient of variation (CV), average real variability, successive variation, variation independent of mean and residual standard deviation. Incident frailty was assessed using the Fried phenotype. Cox proportional hazards models were used for the analyses. Results: Higher SBPV was significantly associated with increased risk of incident frailty (1-sd increase of CV: HR = 1.18, 95% CI [1.02-1.37], p=0.03) after adjustment for demographics, body mass index, stroke, ischemic heart disease, diabetes, heart failure, antihypertensive drugs, systolic BP, MAPT intervention groups and baseline pre-frail status. Similar results were observed with all indicators of variability. DBPV and MAPV were not associated with incident frailty (p=0.6 and p=0.2, respectively). Interestingly, higher PPV was also associated with a greater risk of developing frailty over time (1-sd increase of CV: HR = 1.17, 95% CI [1.01-1.35], p=0.03). Conclusion: Independently of BP, higher SBPV and PPV are major clinical predictors of incident frailty. Our findings support the concept of BP physiological dysregulation underlying the frail state and suggest that controlling BP instability could be a promising interventional target in preventing frailty.

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Abstract WP218: Increased Systolic Blood Pressure Variability Among Diabetic Patients is Associated With Higher Risk of Incident Stroke: A Secondary Analysis of ACCORDION

Stroke ◽

10.1161/str.51.suppl_1.wp218 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Adam H de Havenon ◽

Ka-Ho Wong ◽

Eva Mistry ◽

Mohammad Anadani ◽

Shadi Yaghi ◽

...

Keyword(s):

Blood Pressure ◽

Blood Pressure Variability ◽

Proportional Hazards ◽

Secondary Analysis ◽

Cox Proportional Hazards ◽

Diabetic Patients ◽

Adjusted Risk ◽

Cox Proportional Hazards Models ◽

Increased Risk

Background: Increased blood pressure variability (BPV) has been associated with stroke risk, but never specifically in patients with diabetes. Methods: This is a secondary analysis of the Action to Control Cardiovascular Risk in Diabetes Follow-On Study (ACCORDION), the long term follow-up extension of ACCORD. Visit-to-visit BPV was analyzed using all BP readings during the first 36 months. The primary outcome was incident ischemic or hemorrhagic stroke after 36 months. Differences in mean BPV was tested with Student’s t-test. We fit Cox proportional hazards models to estimate the adjusted risk of stroke across lowest vs. highest quintile of BPV and report hazard ratios along with 95% confidence intervals (CI). Results: Our analysis included 9,241 patients, with a mean (SD) age of 62.7 (6.6) years and 61.7% were male. Mean (SD) follow-up was 5.7 (2.4) years and number of BP readings per patient was 12.0 (4.3). Systolic, but not diastolic, BPV was higher in patients who developed stroke (Table 1). The highest quintile of SBP SD was associated with increased risk of incident stroke, independent of mean blood pressure or other potential confounders. (Table 2, Figure 1). There was no interaction between SBP SD and treatment arm assignment, although the interaction for glucose approached significance (Table 2). Conclusion: Higher systolic BPV was associated with incident stroke in a large cohort of diabetic patients. Future trials of stroke prevention may benefit from interventions targeting BPV reduction.

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Increasing Blood Pressure Variability Predicts Poor Functional Outcome Following Acute Stroke

Journal of Stroke and Cerebrovascular Diseases ◽

10.1016/j.jstrokecerebrovasdis.2020.105466 ◽

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

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The impact of risk factor trends on intracerebral hemorrhage incidence over the last two decades—The Tromsø Study

International Journal of Stroke ◽

10.1177/1747493018789996 ◽

2018 ◽

Vol 14 (1) ◽

pp. 61-68 ◽

Cited By ~ 2

Author(s):

Maria Carlsson ◽

Tom Wilsgaard ◽

Stein Harald Johnsen ◽

Liv-Hege Johnsen ◽

Maja-Lisa Løchen ◽

...

Keyword(s):

Risk Factors ◽

Risk Factor ◽

Intracerebral Hemorrhage ◽

Proportional Hazards ◽

Temporal Trends ◽

Population Based ◽

Incidence Rates ◽

Cox Proportional Hazards ◽

Intracerebral Hemorrhages ◽

The Impact

Background Studies on the relationship between temporal trends in risk factors and incidence rates of intracerebral hemorrhage are scarce. Aims To analyze temporal trends in risk factors and incidence rates of intracerebral hemorrhage using individual data from a population-based study. Methods We included 28,167 participants of the Tromsø Study enrolled between 1994 and 2008. First-ever intracerebral hemorrhages were registered through 31 December 2013. Hazard ratios (HRs) for intracerebral hemorrhage were analyzed by Cox proportional hazards models, risk factor levels over time by generalized estimating equations, and incidence rate ratios (IRR) by Poisson regression. Results We registered 219 intracerebral hemorrhages. Age, male sex, systolic blood pressure (BP), diastolic BP, and hypertension were associated with intracerebral hemorrhage. Hypertension was more strongly associated with non-lobar intracerebral hemorrhage (HR 5.08, 95% CI 2.86–9.01) than lobar intracerebral hemorrhage (HR 1.91, 95% CI 1.12–3.25). In women, incidence decreased significantly (IRR 0.46, 95% CI 0.23–0.90), driven by a decrease in non-lobar intracerebral hemorrhage. Incidence rates in men remained stable (IRR 1.27, 95% CI 0.69–2.31). BP levels were lower and decreased more steeply in women than in men. The majority with hypertension were untreated, and a high proportion of those treated did not reach treatment goals. Conclusions We observed a significant decrease in intracerebral hemorrhage incidence in women, but not in men. A steeper BP decrease in women may have contributed to the diverging trends. The high proportion of untreated and sub-optimally treated hypertension calls for improved strategies for prevention of intracerebral hemorrhage.

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Impact of Model Choice When Studying the Relationship Between Blood Pressure Variability and Risk of Stroke Recurrence

Hypertension ◽

10.1161/hypertensionaha.120.16807 ◽

2021 ◽

Author(s):

Hugues de Courson ◽

Loïc Ferrer ◽

Antoine Barbieri ◽

Phillip J. Tully ◽

Mark Woodward ◽

...

Keyword(s):

Blood Pressure ◽

Blood Pressure Variability ◽

Proportional Hazards ◽

Cox Model ◽

Positive Association ◽

Vascular Risk Factor ◽

Stroke Recurrence ◽

The Impact ◽

Over Time

Long-term blood pressure variability (BPV), an increasingly recognized vascular risk factor, is challenging to analyze. The objective was to assess the impact of BPV modeling on its estimated effect on the risk of stroke. We used data from a secondary stroke prevention trial, PROGRESS (Perindopril Protection Against Stroke Study), which included 6105 subjects. The median number of blood pressure (BP) measurements was 12 per patient and 727 patients experienced a first stroke recurrence over a mean follow-up of 4.3 years. Hazard ratios (HRs) of BPV were estimated from 6 proportional hazards models using different BPV modeling for comparison purposes. The 3 commonly used methods first derived SD of BP measures observed over a given period of follow-up and then used it as a fixed covariate in a Cox model. The 3 more advanced modeling accounted for changes in BP or BPV over time in a single-stage analysis. While the 3 commonly used methods produced contradictory results (for a 5 mmHg increase in BPV, HR=0.75 [95% CI, 0.68–0.82], HR=0.99 [0.91–1.08], HR=1.19 [1.10–1.30]), the 3 more advanced modeling resulted in a similar moderate positive association (HR=1.08 [95% CI, 0.99–1.17]), whether adjusted for BP at randomization or mean BP over the follow-up. The method used to assess BPV strongly affects its estimated effect on the risk of stroke, and should be chosen with caution. Further methodological developments are needed to account for the dynamics of both BP and BPV over time, to clarify the specific role of BPV.

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Periinterventional Vasospasm in Patients With Aneurysmal Subarachnoid Hemorrhage Predicts an Unfavorable Clinical Course

Neurosurgery Open ◽

10.1093/neuopn/okaa021 ◽

2021 ◽

Vol 2 (1) ◽

Author(s):

Serge Marbacher ◽

Benjamin Bircher ◽

Deborah R Vogt ◽

Michael Diepers ◽

Luca Remonda ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Functional Outcome ◽

Proportional Hazards ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Delayed Cerebral Ischemia ◽

Cox Proportional Hazards ◽

World Federation ◽

Warning Sign ◽

Poor Functional Outcome ◽

Delayed Cerebral Vasospasm

ABSTRACT BACKGROUND Preliminary evidence exists that ultra-early angiographic vasospasm (UEAV) after aneurysmal subarachnoid hemorrhage (SAH) is associated with delayed cerebral vasospasm (DCVS), delayed cerebral ischemia (DCI), and poor functional outcome. Typically, detection of UEAV has been based on admission radiological imaging. OBJECTIVE To elucidate the occurrence of the phenomenon of UEAV during treatment in SAH patients. METHODS A total of 206 consecutive patients underwent either endovascular or microsurgical treatment in a hybrid operating room within 48 h after SAH. Time to DCVS and DCI, and poor functional outcome (both binary) were analyzed using Cox proportional-hazards and logistic regression models. We examined both univariable models (admission and periinterventional UEAV) and multivariable models (backward variable selection, including further known and suspected risk factors). RESULTS For UEAV detected in 33 patients (16%), 10 were admission and periinterventional and 23 periinterventional only. Both admission and periinterventional UEAV significantly increased the risk of DCVS (hazard ratio [HR] 1.7, 95% confidence interval [CI] 1.2–2.3, P = .001), DCI (odds ratio [OR] 5.9, CI 1.7-25.1, P = .001), and poor functional outcome (OR 4.7, CI 1.7-13.4, P = .004). Clipping, female sex, and higher Barrow Neurological Institute (BNI) scale increased the hazard for DCVS and the probability for DCI, whereas increasing patient age, poor initial World Federation of Neurological Surgeons (WFNS) grade, and intraparenchymal hemorrhage increased the probability for poor functional outcome. CONCLUSION Detection of admission or periinterventional UEAV poses high risk of DCVS, DCI, and poor outcome after SAH. Therefore, periinterventional UEAV should be considered an important warning sign that warrants both early monitoring and aggressive therapy.

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Satellite Sign: A Poor Outcome Predictor in Intracerebral Hemorrhage

Cerebrovascular Diseases ◽

10.1159/000477179 ◽

2017 ◽

Vol 44 (3-4) ◽

pp. 105-112 ◽

Cited By ~ 25

Author(s):

Yoshiteru Shimoda ◽

Satoru Ohtomo ◽

Hiroaki Arai ◽

Ken Okada ◽

Teiji Tominaga

Keyword(s):

Blood Pressure ◽

Logistic Regression ◽

Intracerebral Hemorrhage ◽

Functional Outcome ◽

Multivariate Logistic Regression Analysis ◽

High Density ◽

Multivariate Logistic Regression ◽

Poor Functional Outcome ◽

Poor Outcome ◽

Intraventricular Bleeding

Background: The presence of high-density starry dots around the intracerebral hemorrhage (ICH), which we termed as a satellite sign, is occasionally observed in CT. The relationship between ICH with a satellite sign and its functional outcome has not been identified. This study aimed to determine whether the presence of a satellite sign could be an independent prognostic factor for patients with ICH. Methods: Patients with acute spontaneous ICH were retrospectively identified and their initial CT scans were reviewed. A satellite sign was defined as scattered high-density lesions completely separate from the main hemorrhage in at least the single axial slice. Functional outcome was evaluated using the modified Rankin Scale (mRS) at discharge. Poor functional outcome was defined as mRS scores of 3-6. Univariate and multivariate logistic regression analyses were applied to assess the presence of a satellite sign and its association with poor functional outcome. Results: A total of 241 patients with ICH were enrolled in the study. Of these, 98 (40.7%) had a satellite sign. Patients with a satellite sign had a significantly higher rate of poor functional outcome (95.9%) than those without a satellite sign (55.9%, p < 0.0001). Multivariate logistic regression analysis revealed that higher age (OR 1.06; 95% CI 1.03-1.10; p = 0.00016), large hemorrhage size (OR 1.06; 95% CI 1.03-1.11; p = 0.00015), and ICH with a satellite sign (OR 13.5; 95% CI 4.42-53.4; p < 0.0001) were significantly related to poor outcome. A satellite sign was significantly related with higher systolic blood pressure (p = 0.0014), higher diastolic blood pressure (p = 0.0117), shorter activated partial thromboplastin time (p = 0.0427), higher rate of intraventricular bleeding (p < 0.0001), and larger main hemorrhage (p < 0.0001). Conclusions: The presence of a satellite sign in the initial CT scan is associated with a significantly worse functional outcome in ICH patients.

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The impact of day-by-day blood pressure variability on neurological functional outcome after acute ischemic stroke

European Heart Journal ◽

10.1093/ehjci/ehaa946.2723 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

C.Q Yang ◽

X.P Chen

Keyword(s):

Risk Factors ◽

Blood Pressure ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Functional Outcome ◽

Blood Pressure Variability ◽

Unfavorable Outcome ◽

Baseline Severity ◽

The Impact ◽

Day By Day

Abstract Background Increased blood pressure variability (BPV) might be a detrimental factor after acute ischemic stroke. Previous studies on the association between blood pressure variability in the acute ischemic stroke and neurological functional outcome have yielded inconsistent results. Purpose We aimed to investigate the impact of day-by-day blood pressure variability within 7 days of onset on neurological functional outcome at 3 months after acute ischemic stroke. Methods Total 367 patients hospitalized for ischemic stroke within 48 hours of onset were enrolled. The acute stage of ischemic stroke was defined as the time period from symptom onset to 7 days. During this period, day-by-day blood pressure variability, including standard deviation (SD) and coefficient variation (CV) were derived and compared to neurological functional outcome. A baseline severity-adjusted analysis was performed using 3-month modified Rankin Scale score as the neurological functional outcome. Unfavorable outcome was defined as mRS≥3. Results The patients with unfavorable outcome had significantly higher systolic BPV (within 7 days of onset) than those with favorable outcome (15.41±4.59 VS 13.42±3.95mmHg for SD, P<0.001; 11.54±3.23 VS 10.41±2.82 for CV, P=0.001). Multivariable logistic regression analysis revealed that Systolic BPV was significantly and independently associated with the 3-month neurological functional outcome (odds ratio [OR] = 1.15, 95% confidence interval [CI]: 1.07–1.22, P<0.001 for SD; OR=1.15, 95% CI: 1.06–1.26, P=0.001 for CV). In addition, After adjustment for multiple confounding factors, including age, gender, risk factors, stroke features, baseline severity, recanalized therapy, hemorrhagic transformation, pulmonary infection, white blood cell, estimated Glomerular Filtration Rate and mean BP, day-by-day BP variability was significantly correlated with an unfavorable outcome in the top versus bottom quartile of systolic BP variability (OR=3.33, 95% CI: 1.41–7.85, P=0.006 for SD; OR=2.27, 95% CI: 1.04–4.94, P=0.037 for CV) during 3-month follow-up. Similar trends were also observed for diastolic BP variability. More importantly, incorporating SD of systolic BP into the conventional prediction model significantly increased the AUC for prediction of 3-month unfavorable outcome after acute ischemic stroke (0.84 vs 0.86; P=0.041). Conclusions Increased day-by-day blood pressure variability of systolic or diastolic BP in the acute ischemic stroke was associated with higher risk for unfavorable outcome at 3 months independent of mean blood pressure. Combining SD of systolic BP with conventional risk factors could thus improve the prediction of unfavorable outcome. Funding Acknowledgement Type of funding source: None

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