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Kakaletsis N, Ntaios G, Milionis H, Karagiannaki A, Chouvarda I, Dourliou V, Ladakis I, Kaiafa G, Vemmos K, Savopoulos C. Midday Dipping and Circadian Blood Pressure Patterns in Acute Ischemic Stroke. J Clin Med 2023; 12:4816. [PMID: 37510931 PMCID: PMC10381256 DOI: 10.3390/jcm12144816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/14/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023] Open
Abstract
The purpose of this study was to investigate the alterations in blood pressure (BP) during midday and the changes in circadian BP patterns in the acute phase of ischemic stroke (AIS) with the severity of stroke and their predictive role outcomes within 3 months. A total of 228 AIS patients (a prospective multicenter follow-up study) underwent 24 h ambulatory blood pressure monitoring (ABPM). Mean BP parameters during the day (7:00-22:59), the midday (13:00-16:59), and the night (23:00-6:59), and midday and nocturnal dipping were calculated. Midday SBP dippers had less severe stroke, lower incidence of hypertension and SBP/DBP on admission, lower levels of serum glucose and WBCs, and delayed initiation of ABPM compared to risers. There was a reverse relation between midday SBP dipping and both nocturnal dipping and stroke severity. The "double dippers" (midday and nocturnal dipping) had the least severe stroke, the lowest SBP/DBP on admission, the lowest heart rate from ABPM, and a lower risk of an unfavorable outcome, while the "double risers" had the opposite results, by an approximately five-fold risk of death/disability at 3 months. These findings indicate different circadian BP patterns during the acute phase of AIS, which could be considered a marker of stroke severity and prognosis.
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Affiliation(s)
- Nikolaos Kakaletsis
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, 54636 Thessaloniki, Greece
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, 35100 Larissa, Greece
| | - Haralampos Milionis
- Department of Internal Medicine, Medical School, University of Ioannina, University Hospital of Ioannina, 45500 Ioannina, Greece
| | - Anastasia Karagiannaki
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, 35100 Larissa, Greece
| | - Ioanna Chouvarda
- Laboratory of Computing, Medical Informatics and Biomedical-Imaging Technologies, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece
| | - Vasiliki Dourliou
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, 54636 Thessaloniki, Greece
| | - Ioannis Ladakis
- Laboratory of Computing, Medical Informatics and Biomedical-Imaging Technologies, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece
| | - Georgia Kaiafa
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, 54636 Thessaloniki, Greece
| | | | - Christos Savopoulos
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, 54636 Thessaloniki, Greece
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Kakaletsis N, Ntaios G, Milionis H, Karagiannaki A, Chouvarda I, Dourliou V, Chytas A, Hatzitolios AI, Savopoulos C. Prognostic significance of 24-h blood pressure and variability indices in the outcome of acute ischaemic stroke. Intern Med J 2023; 53:1137-1146. [PMID: 35666577 DOI: 10.1111/imj.15834] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 05/29/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The association between blood pressure (BP) levels and BP variability (BPV) following acute ischaemic stroke (AIS) and outcome remains controversial. AIMS To investigate the predictive value of systolic BP (SBP) and diastolic BP (DBP) and BPV measured using 24-h ambulatory blood pressure monitoring (ABPM) methods during AIS regarding outcome. METHODS A total of 228 AIS patients (175 without prior disability) underwent ABPM every 20 min within 48 h from onset using an automated oscillometric device (TM 2430, A&D Company Ltd) during day time (7:00-22:59) and night time (23:00-6:59). Risk factors, stroke subtypes, clinical and laboratory findings were recorded. Mean BP parameters and several BPV indices were calculated. End-points were death and unfavourable functional outcome (disability/death) at 3 months. RESULTS A total of 61 (26.7%) patients eventually died. Multivariate logistic regression analysis revealed that only mean night-time DBP (hazard ratio (HR): 1.04; 95% confidence interval (CI): 1.00-1.07) was an independent prognostic factor of death. Of the 175 patients without prior disability, 79 (45.1%) finally met the end-point of unfavourable functional outcome. Mean 24-h SBP (HR: 1.03; 95% CI: 1.00-1.05), day-time SBP (HR: 1.02; 95% CI: 1.00-1.05) and night-time SBP (HR: 1.03; 95% CI: 1.01-1.05), SBP nocturnal decline (HR: 0.93; 95% CI: 0.88-0.99), mean 24-h DBP (HR: 1.08; 95% CI: 1.03-1.13), day-time DBP (HR: 1.07; 95% CI: 1.03-1.12) and night-time DBP (HR: 1.06; 95% CI: 1.02-1.10) were independent prognostic factors of an unfavourable functional outcome. CONCLUSIONS In contrast with BPV indices, ABPM-derived BP levels and lower or absence of BP nocturnal decline in the acute phase are prognostic factors of outcome in AIS patients.
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Affiliation(s)
- Nikolaos Kakaletsis
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Haralampos Milionis
- Department of Internal Medicine, Medical School, University of Ioannina, University Hospital of Ioannina, Ioannina, Greece
| | - Anastasia Karagiannaki
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Ioanna Chouvarda
- Laboratory of Medical Informatics, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasiliki Dourliou
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Achileas Chytas
- Laboratory of Medical Informatics, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Apostolos I Hatzitolios
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Christos Savopoulos
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
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Weiss A, Beloosesky Y, Kenett RS, Grossman E. Change in Systolic Blood Pressure During Stroke, Functional Status, and Long-Term Mortality in an Elderly Population. Am J Hypertens 2016. [PMID: 26208674 DOI: 10.1093/ajh/hpv118] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Elevated systolic blood pressure (SBP) recorded by 24-hour blood pressure monitoring (24H BPM) on the first day of acute stroke is associated in elderly patients, with an unfavorable outcome. Herein, we assessed, by 24H BPM, the impact of the change in SBP levels during the first week of stroke on short-term functional status and long-term mortality in elderly patients. METHODS One hundred and fifty acute stroke patients (69 males), mean age at admission 83.6±5.5 years, 82% with ischemic stroke, were investigated. 24H BPM was recorded within 24 hours of admission and 1 week later. After 7 days, patients were assessed for functional status according to the modified Rankin scale (mRS) and were subsequently followed for mortality up to 7.5 years (mean 3.16±2.29). RESULTS After 7 days, SBP decreased from 147±21 to 140±20 mm Hg (P < 0.001). Functional status improved and mRS decreased from 4.2 to 3.7. During follow-up, 58 patients (17 males and 41 females) had died. Mortality rate was higher in females (69% vs. 45%; P < 0.01) and in patients with a history of congestive heart failure. The average admission SBP predicted short-term functional status and long-term mortality. However, the change in SBP corrected for admission levels, gender, age and other variables was not associated with short-term functional status and long-term mortality. CONCLUSION There is no evidence of association between change in SBP during the first week of stroke and short-term functional status and long-term mortality in this group of stroke patients.
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Affiliation(s)
- Avraham Weiss
- Geriatric Ward, Rabin Medical Center, Petach Tikvah, Israel
| | | | | | - Ehud Grossman
- Department of Internal Medicine D and Hypertension Unit, The Chaim Sheba Medical Center, Tel-Hashomer, Affiliated to Sackler School of Medicine, Tel-Aviv University, Israel.
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Nagy AD, Reddy AB. Time dictates: emerging clinical analyses of the impact of circadian rhythms on diagnosis, prognosis and treatment of disease. Clin Med (Lond) 2015; 15 Suppl 6:s50-3. [PMID: 26634682 PMCID: PMC4768354 DOI: 10.7861/clinmedicine.15-6-s50] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Since the advent of modern molecular tools, researchers have extensively shown that essential cellular machineries have robust circadian (roughly 24 hours) variations in their pace. This molecular rhythmicity translates directly into time-of-day-dependent variation in physiology in most organ systems, which in turn provides the mechanistic rationale for why timing on a daily basis should matter in many aspects of human health. However, these basic science findings have been slow to move from bench to bedside because clinical studies are still lacking to demonstrate the importance of timing. Therefore, it has not been clear how physicians should incorporate knowledge of natural 24-hour rhythms into routine practice. This review is a brief summary of results from recently completed clinical studies on hypertension, myocardial infarction, diabetes mellitus, and adrenal dysfunction that highlights new evidence for the emerging importance of circadian rhythms in diagnosis, prognosis and treatment of disease.
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Affiliation(s)
- Andras D. Nagy
- Department of Clinical Neurosciences, University of Cambridge Metabolic Research Laboratories, National Institutes of Health Biomedical Research Centre, and Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Addenbrooke’s Hospital, Cambridge CB2 0QQ, United Kingdom
- Department of Anatomy, University of Pécs Medical School, Pécs, Hungary
| | - Akhilesh B. Reddy
- Department of Clinical Neurosciences, University of Cambridge Metabolic Research Laboratories, National Institutes of Health Biomedical Research Centre, and Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Addenbrooke’s Hospital, Cambridge CB2 0QQ, United Kingdom
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Kakaletsis N, Ntaios G, Milionis H, Haidich AB, Makaritsis K, Savopoulos C, Berge E, Hatzitolios AI. Prognostic Value of 24-H ABPM in Acute Ischemic Stroke for Short-, Medium-, and Long-Term Outcome: A Systematic Review and Meta-Analysis. Int J Stroke 2015; 10:1000-7. [DOI: 10.1111/ijs.12609] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Accepted: 06/01/2015] [Indexed: 11/26/2022]
Abstract
Background The association of blood pressure levels during the acute phase of ischemic stroke with outcome remains controversial. Aims The objective of this systematic review is to assess the predictive value for stroke outcome assessed by the modified Rankin scale score of systolic and diastolic blood pressure, measured by ambulatory blood pressure monitoring methods during the acute phase of ischemic stroke, compared with the values of casually derived blood pressure measurement on admission. Methods We searched for studies with patients admitted within 24 h of stroke onset, and who had ambulatory blood pressure monitoring during the first 24 h of admission. We identified studies that reported blood pressure in those with good outcome and in those with poor outcome at end of follow-up, and performed a meta-analysis of the effect of mean blood pressure on outcome. Results High systolic and diastolic blood pressure levels derived with ambulatory blood pressure monitoring were associated with poor short-, medium-, and long-term outcome, but the same was not found for casual blood pressure measurements. An increase in systolic blood pressure of 9·1 mmHg (95% confidence interval: 6·6–11·6, P < 0·001; I2 = 9%) and an increase in diastolic blood pressure of 2·3 mmHg (95% confidence interval: 0·8–3·7, P = 0·002; I2 = 0%) were associated with poor outcome. Conclusions Higher systolic and diastolic blood pressure levels derived with ambulatory blood pressure monitoring were associated with poor outcome. The same was not found for higher casual blood pressure measurements on admission, and it is possible that ambulatory blood pressure monitoring conveys better prognostic information.
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Affiliation(s)
- Nikolaos Kakaletsis
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - George Ntaios
- Department of Medicine, Medical School, University of Thessaly, Larissa, Greece
| | - Haralampos Milionis
- Department of Internal Medicine, Medical School, University of Ioannina, University Hospital of Ioannina, Ioannina, Greece
| | - Anna-Bettina Haidich
- Department of Hygiene and Epidemiology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Christos Savopoulos
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Eivind Berge
- Department of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | - Apostolos I. Hatzitolios
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
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Jensen MB, Yoo B, Clarke WR, Davis PH, Adams HR. Blood Pressure as an Independent Prognostic Factor in Acute Ischemic Stroke. Can J Neurol Sci 2014; 33:34-8. [PMID: 16583719 DOI: 10.1017/s0317167100004662] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND PURPOSE Blood pressure is elevated in most patients during acute ischemic stroke, but the prognostic significance of this is unclear as the current data yield conflicting results. METHODS Admission blood pressure from the 1281 patients in the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) was analyzed for prognostic significance as well as the risk of hemorrhagic transformation. We also examined weighted-average blood pressure over seven days, and the impact of a 30% change in blood pressure in 24 hours. Patients with severe hypertension were excluded from the TOAST trial. RESULTS Increasing systolic blood pressure (SBP) on admission, but not diastolic (DBP) or mean arterial pressure (MAP) was predictive of poor outcome, but this effect was not significant after adjustment for other know prognostic factors. Increasing weighted-average SBP and MAP over seven days were predictive for poor outcome, but a 30% change in blood pressure over 24 hours was not. CONCLUSIONS Admission blood pressure is not an independent prognostic factor in acute ischemic stroke, but the weighted-average of SBP and MAP over seven days probably does have predictive value with higher values having a worse prognosis. A prospective trial of blood pressure control during acute stroke is needed.
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Affiliation(s)
- Matt B Jensen
- Stroke Center, University of California, San Diego, CA 92103-8466, USA
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Park JH, Lee HS, Kim JH, Lee JH, Kim J, Choi SW. Reverse Dipper and High Night-time Heart Rate in Acute Stage of Cerebral Infarction Are Associated with Increased Mortality. J Stroke Cerebrovasc Dis 2014; 23:1171-6. [DOI: 10.1016/j.jstrokecerebrovasdis.2013.10.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 10/03/2013] [Accepted: 10/09/2013] [Indexed: 11/26/2022] Open
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Intensive Blood Pressure–Lowering Treatment in Patients with Acute Lacunar Infarction. J Stroke Cerebrovasc Dis 2013; 22:1273-8. [DOI: 10.1016/j.jstrokecerebrovasdis.2012.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Revised: 08/30/2012] [Accepted: 09/16/2012] [Indexed: 11/17/2022] Open
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Weiss A, Beloosesky Y, Kenett RS, Grossman E. Systolic Blood Pressure During Acute Stroke Is Associated With Functional Status and Long-term Mortality in the Elderly. Stroke 2013; 44:2434-40. [DOI: 10.1161/strokeaha.113.001894] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background and Purpose—
The prognostic value of blood pressure (BP) levels during acute stroke has not been adequately studied. Most studies do not use continuous BP measurements, and patients are followed only for a short period. We designed a study to assess, with 24-hour BP monitoring (24H BPM), the impact of BP levels during the first day of stroke, on the short-term functional status and long-term mortality in elderly patients.
Methods—
We studied 177 patients with acute stroke (89 men), mean age 84±6 years. BP was measured on admission and 24H BPM was recorded within 24 hours of admission. After 7 days, patients were assessed for functional status according to the modified Rankin Scale and were subsequently followed up for mortality ≤5 years (mean, 2.07±1.48).
Results—
After 7 days, functional status improved and modified Rankin Scale decreased from 4.2 to 3.7. Follow-up analysis disclosed that 71 patients (27 men and 44 women) had died. Mortality rate was higher in women (50% versus 30%;
P
<0.01) and in patients with a history of congestive heart failure. Only average systolic BP, recorded by 24H BPM, predicted short-term functional status and long-term mortality. Cox proportional hazards model analysis demonstrated that age, sex, congestive heart failure, and average systolic BP >160 mm Hg, recorded by 24H BPM, were associated with increased mortality.
Conclusions—
High systolic BP recorded by 24H BPM on the first day of stroke was found to be associated with unfavorable short-term functional status and long-term mortality in elderly patients.
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Affiliation(s)
- Avraham Weiss
- From the Geriatric Ward, Rabin Medical Center, Petach Tikvah, Israel (A.W., Y.B.); KPA and Department of Applied Mathematics and Statistics, University of Turin, Turin, Italy (R.S.K.); Department of Internal Medicine D and Hypertension Unit, The Chaim Sheba Medical Center, Tel-Hashomer, Israel (E.G.); and Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel (A.W., Y.B., E.G.)
| | - Yichayaou Beloosesky
- From the Geriatric Ward, Rabin Medical Center, Petach Tikvah, Israel (A.W., Y.B.); KPA and Department of Applied Mathematics and Statistics, University of Turin, Turin, Italy (R.S.K.); Department of Internal Medicine D and Hypertension Unit, The Chaim Sheba Medical Center, Tel-Hashomer, Israel (E.G.); and Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel (A.W., Y.B., E.G.)
| | - Ron S. Kenett
- From the Geriatric Ward, Rabin Medical Center, Petach Tikvah, Israel (A.W., Y.B.); KPA and Department of Applied Mathematics and Statistics, University of Turin, Turin, Italy (R.S.K.); Department of Internal Medicine D and Hypertension Unit, The Chaim Sheba Medical Center, Tel-Hashomer, Israel (E.G.); and Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel (A.W., Y.B., E.G.)
| | - Ehud Grossman
- From the Geriatric Ward, Rabin Medical Center, Petach Tikvah, Israel (A.W., Y.B.); KPA and Department of Applied Mathematics and Statistics, University of Turin, Turin, Italy (R.S.K.); Department of Internal Medicine D and Hypertension Unit, The Chaim Sheba Medical Center, Tel-Hashomer, Israel (E.G.); and Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel (A.W., Y.B., E.G.)
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10
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Abstract
The purpose of this review is to highlight existing literature on the epidemiology, pathophysiology, and treatments of stroke sleep disorders. Stroke sleep disorders are associated with many intermediary vascular risk factors leading to stroke, but they may also influence these risk factors through direct or indirect mechanisms. Sleep disturbances may be further exacerbated by stroke or caused by stroke. Unrecognized and untreated sleep disorders may influence rehabilitation efforts and poor functional outcomes following stroke and increase risk for stroke recurrence. Increasing awareness and improving screening for sleep disorders is paramount in the primary and secondary prevention of stroke and in improving stroke outcomes. Many vital questions about the relationship of sleep disorders and stroke are still unanswered and await future well-designed studies.
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Affiliation(s)
- Douglas M Wallace
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
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11
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Weiss A, Beloosesky Y, Majadla R, Grossman E. Blood Pressure Monitoring in the Assessment of Old Patients with Acute Stroke. Int J Stroke 2011; 6:182-6. [DOI: 10.1111/j.1747-4949.2011.00592.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Most patients have elevated blood pressure in the early phase of acute stroke that it often returns to normal within approximately seven-days. Most available data on the pattern of blood pressure in acute stroke are based on manual blood pressure measurements. Aims The aims of the present study were to assess with 24 h blood pressure monitoring the pattern of blood pressure in acute stroke, and the change in blood pressure during the first week of event in very old patients. Methods We studied 99 patients with acute stroke (58 males), mean age 83 ± 6 years (range 70–97). Casual blood pressure and 24 h blood pressure monitoring were recorded within 24 h of admission, and then after six- to seven-days. Results Casual blood pressure before beginning the 24 h blood pressure monitoring was 154 ± 23/80 ± 15 mmHg and the average 24 h blood pressure was 147 ± 20/74 ± 11 mmHg. One-week after stroke, casual blood pressure decreased by 15/7 mmHg, whereas 24 h blood pressure decreased by only 7/2 mmHg ( P<0·01). Blood pressure decreased remarkably only in those with admission elevated systolic blood pressure. The change in 24 h systolic blood pressure after one-week correlated to the 24 h admission systolic blood pressure ( R=0·47; P<0·01). Conclusions Casual blood pressure may overestimate blood pressure in stroke patients. Very old patients with stroke exhibit a mild increase in blood pressure during the acute phase, and blood pressure decreases spontaneously only in those with elevated blood pressure levels. Use of 24 h blood pressure monitoring may be helpful in elderly patients with acute stroke.
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Affiliation(s)
- Avraham Weiss
- Geriatric Ward, Rabin Medical Center, Petach Tikva, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yichayaou Beloosesky
- Geriatric Ward, Rabin Medical Center, Petach Tikva, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Riad Majadla
- Geriatric Ward, Rabin Medical Center, Petach Tikva, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ehud Grossman
- Department of Internal Medicine D and Hypertension Unit, The Chaim Sheba Medical Center, Tel-Hashomer, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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12
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Ali K, Leong KMW, Houlder S, Getov S, Lee R, Rajkumar C. The relationship between dipping profile in blood pressure and neurologic deficit in early acute ischemic stroke. J Stroke Cerebrovasc Dis 2010; 20:10-15. [PMID: 20538485 DOI: 10.1016/j.jstrokecerebrovasdis.2009.09.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2009] [Revised: 09/15/2009] [Accepted: 09/21/2009] [Indexed: 11/18/2022] Open
Abstract
Blood pressure (BP) in healthy individuals exhibits a diurnal variation, with a nighttime dip of 10%-20%. A persistently high nighttime BP is associated with increased cardiovascular morbidity. The effects of diurnal BP variations on the neurologic deficit in acute stroke at presentation and in the first few weeks poststroke are unclear. We hypothesized that persistently elevated BP results in poor outcome. Patients with an acute ischemic stroke presenting within 48 hours of onset underwent 24-hour ambulatory monitoring of systolic, diastolic, and mean BP. There were a total of 35 patients (16 males; mean age, 74 ± 14 years). The percentage change between mean day and night BP classified patients into dippers (> 10% change), nondippers (0-10% change), or reverse-dippers (< 0% change). The Scandinavian Stroke Scale (SSS) and the National Institute of Health Stroke Scale (NIHSS) were assessed on admission, at week 1, and at week 3. The relationship between neurologic score and dipping classification was analyzed using analysis of variance and analysis of covariance, with age and baseline score as covariates. Based on both the SSS and NIHSS, the reverse-dippers had the lowest neurologic scores at baseline, week 1, and week 3, followed by the nondippers. The dippers performed the best in comparison. No significant differences in demographics and/or other BP characteristics among the groups that could account for these differences in outcome were noted. A reverse-dipping profile in diastolic BP was associated with poor neurologic state at baseline and weeks 1 and 3 compared with both dippers and nondippers.
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Affiliation(s)
- Khalid Ali
- Academic Department of Geriatrics, Brighton and Sussex Medical School, Brighton, UK.
| | | | | | - Spas Getov
- Brighton & Sussex University Hospitals Trust, Brighton, UK
| | - Richard Lee
- Brighton & Sussex University Hospitals Trust, Brighton, UK
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Abstract
Obstructive sleep apnea (OSA) and stroke are frequent, multifactorial entities that share risk factors, and for which case-control and cross-sectional studies have shown a strong association. Stroke of respiratory centers can lead to apnea. Snoring preceding stroke, documentation of apneas immediately prior to transient ischemic attacks, the results of autonomic studies, and the circadian pattern of stroke, suggest that untreated OSA can contribute to stroke. Although cohort studies indicate that OSA is a stroke risk factor, controversy surrounds the cost-effectiveness of the screening for and treatment of OSA once stroke has occurred.
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Affiliation(s)
- Mark Eric Dyken
- Sleep Disorders Center, the Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA.
| | - Kyoung Bin Im
- Sleep Disorders Center, the Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA
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14
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Castilla-Guerra L, Espino-Montoro A, Fernandez-Moreno MC, López-Chozas JM. Abnormal Blood Pressure Circadian Rhythm in Acute Ischaemic Stroke: are Lacunar Strokes Really Different? Int J Stroke 2009; 4:257-61. [DOI: 10.1111/j.1747-4949.2009.00314.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Background A pathologically reduced or abolished circadian blood pressure variation has been described in acute stroke. However, studies on alterations of circadian blood pressure patterns after stroke and stroke subtypes are scarce. The objective of this study was to evaluate the changes in circadian blood pressure patterns in patients with acute ischaemic stroke and their relation to the stroke subtype. Aims We studied 98 consecutive patients who were admitted within 24 h after ischaemic stroke onset. All patients had a detailed clinical examination, laboratory studies and a CT scan study of the brain on admission. To study the circadian rhythm of blood pressure, a continuous blood pressure monitor (Spacelab 90217) was used. Patients were classified according to the percentage fall in the mean systolic blood pressure or diastolic blood pressure at night compared with during the day as: dippers (fall ≥ 10–20%); extreme dippers (≥20%); nondipper (<10%); and reverse dippers (<0%, that is, an increase in the mean nocturnal blood pressure compared with the mean daytime blood pressure). Data were separated and analysed in two groups: lacunar and nonlacunar infarctions. Statistical testing was conducted using the SSPS 12.0. Methods We studied 60 males and 38 females, mean age: 70·5 ± 11 years. The patient population consisted of 62 (63·2%) lacunar strokes and 36 (36·8%) nonlacunar strokes. Hypertension was the most common risk factor (67 patients, 68·3%). Other risk factors included hypercholesterolaemia (44 patients, 44·8%), diabetes mellitus (38 patients, 38·7%), smoking (24 patients, 24·8%) and atrial fibrillation (19 patients, 19·3%). The patients with lacunar strokes were predominantly men ( P = 0·037) and had a lower frequency of atrial fibrillation ( P = 0·016) as compared with nonlacunar stroke patients. In the acute phase, the mean systolic blood pressure was 136±20 mmHg and diastolic blood pressure was 78·7 ± 11·8. Comparing stroke subtypes, there were no differences in 24·h systolic blood pressure and 24-h diastolic blood pressure between patients with lacunar and nonlacunar infarction. However, patients with lacunar infarction showed a mean decline in day–night systolic blood pressure and diastolic blood pressure of approximately 4 mmHg [systolic blood pressure: 3·9 (SD 10) mmHg, P = 0·003; diastolic blood pressure 3·7 (SD 7) mmHg, P = 0·0001] compared with nonlacunar strokes. Nonlacunar strokes showed a lack of 24-h nocturnal systolic blood pressure and diastolic blood pressure fall. The normal diurnal variation in systolic blood pressure was abolished in 87 (88·9%) patients, and the variation in diastolic blood pressure was abolished in 76 (77·5%) patients. On comparing lacunar and nonlacunar strokes, we found that the normal diurnal variation in systolic blood pressure was abolished in 53 (85·4%) lacunar strokes and in 34 (94·4%) nonlacunar strokes ( P = nonsignificant). In terms of diurnal variation in diastolic blood pressure, it was abolished in 43 (69·3%) lacunar strokes and in 33 (91·6%) nonlacunar strokes ( P = 0·026). Conclusions Our results show clear differences in the blood pressure circadian rhythm of acute ischaemic stroke between lacunar and nonlacunar infarctions by means of 24-h blood pressure monitoring. The magnitude of nocturnal systolic and diastolic blood pressure dip was significantly higher in lacunar strokes. Besides, patients with lacunar strokes presented a higher percentage of dipping patterns in the diastolic blood pressure circadian rhythm. Therefore, one should consider the ischaemic stroke subtype when deciding on the management of blood pressure in acute stroke.
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Affiliation(s)
| | - A. Espino-Montoro
- Department of Internal Medicine, Hospital de la Merced, Osuna, Seville, Spain
| | | | - J. M. López-Chozas
- Department of Internal Medicine, Hospital Virgen del Rocio, Seville, Spain
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15
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Wong AA, Read SJ. Early changes in physiological variables after stroke. Ann Indian Acad Neurol 2008; 11:207-20. [PMID: 19893676 PMCID: PMC2771993 DOI: 10.4103/0972-2327.44555] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2007] [Revised: 09/23/2008] [Accepted: 09/23/2008] [Indexed: 01/04/2023] Open
Abstract
Several aspects of physiology, notably blood pressure, body temperature, blood glucose, and blood oxygen saturation, may be altered after an ischemic stroke and intracerebral hemorrhage. Generally, blood pressure and temperature rise acutely after a stroke, before returning to normal. Blood glucose and oxygen levels may be abnormal in individuals, but they do not follow a set pattern. Several aspects of these physiological alterations remain unclear, including their principal determinants - whether they genuinely affect prognosis (as opposed to merely representing underlying processes such as inflammation or a stress response), whether these effects are adaptive or maladaptive, whether the effects are specific to certain subgroups (e.g. lacunar stroke) and whether modifying physiology also modifies its prognostic effect. Hypertension and hyperglycemia may be helpful or harmful, depending on the perfusion status after an ischemic stroke; the therapeutic response to their lowering may be correspondingly variable. Hypothermia may provide benefits, in addition to preventing harm through protection from hyperthermia. Hypoxia is harmful, but normobaric hyperoxia is unhelpful or even harmful in normoxic patients. Hyperbaric hyperoxia, however, may be beneficial, though this remains unproven. The above-mentioned uncertainties necessitate generally conservative measures for physiology management, although there are notably specific recommendations for thrombolysis-eligible patients. Stroke unit care is associated with better outcome, possibly through better management of poststroke physiology. Stroke units can also facilitate research to clarify the relationship between physiology and prognosis, and to subsequently clarify management guidelines.
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Affiliation(s)
- Andrew A Wong
- Department of Neurology, Princess Alexandra Hospital, Brisbane, Queensland, Australia. Central Clinical School, School of Medicine, University of Queensland, Brisbane, Queensland, Australia.
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16
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17
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Jones SP, Leathley MJ, McAdam JJ, Watkins CL. Physiological monitoring in acute stroke: a literature review. J Adv Nurs 2007; 60:577-94. [DOI: 10.1111/j.1365-2648.2007.04510.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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18
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Pandian JD, Wong AA, Lincoln DJ, Davis JP, Henderson RD, O' Sullivan JD, Read SJ. Circadian blood pressure variation after acute stroke. J Clin Neurosci 2006; 13:558-62. [PMID: 16678424 DOI: 10.1016/j.jocn.2005.09.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2005] [Accepted: 09/08/2005] [Indexed: 11/16/2022]
Abstract
We aimed to characterise the patterns of circadian blood pressure (BP) variation after acute stroke and determine whether any relationship exists between these patterns and stroke outcome. BP was recorded manually every 4 h for 48 h following acute stroke. Patients were classified according to the percentage fall in mean systolic BP (SBP) at night compared to during the day as: dippers (fall > or = 10-<20%); extreme dippers (> or = 20%); non-dippers (> or = 0-<10%); and reverse dippers (<0%, that is, a rise in mean nocturnal SBP compared to mean daytime SBP). One hundred and seventy-three stroke patients were included in the study (83 men, 90 women; mean age 74.3 years). Four patients (2.3%) were extreme dippers, 25 (14.5%) dippers, 80 (46.2%) non-dippers and 64 (36.9%) reverse dippers. There was a non-significant trend in the proportion of patients who were dead or dependent at 3 months in the extreme dipper (p=0.59) and reverse dipper (p=0.35) groups. Non-dipping and reverse-dipping were relatively common patterns of circadian BP variation seen in acute stroke patients. These patterns were not clearly associated with outcome.
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Affiliation(s)
- Jeyaraj D Pandian
- Stroke Unit, Department of Neurology, Level 7, Ned Hanlon Building, Royal Brisbane and Women's Hospital, Herston Road, Brisbane, Queensland 4029, Australia.
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19
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Spengos K, Tsivgoulis G, Zakopoulos N. Blood pressure management in acute stroke: a long-standing debate. Eur Neurol 2006; 55:123-35. [PMID: 16682796 DOI: 10.1159/000093212] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2006] [Accepted: 03/15/2006] [Indexed: 11/19/2022]
Abstract
Although elevated blood pressure (BP) levels are a common complication of acute stroke, whether of ischaemic or haemorrhagic type, a long-standing debate exists regarding the management of post-stroke hypertension. In the absence of solid, randomised data from controlled trials, the current observational evidence allows different approaches, since theoretical arguments exist for both lowering BP in the setting of acute stroke (reduce the risk of stroke recurrence, of subsequent oedema formation, of rebleeding and haematoma expansion in patients with cerebral bleeding) as well as leaving raised BP levels untreated (avoid reduction in cerebral perfusion pressure and blood flow to viable ischaemic tissue in the absence of normal autoregulation). The present review will summarize the evidence for and against the therapeutic manipulation of BP in acute stroke provided by the currently available observational studies and randomised trials, consider the ongoing clinical trials in this area and address the present recommendations regarding this conflicting issue.
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Affiliation(s)
- Konstantinos Spengos
- Department of Neurology, University of Athens School of Medicine, Eginition Hospital, Greece.
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20
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Selic C, Siccoli MM, Hermann DM, Bassetti CL. Blood Pressure Evolution After Acute Ischemic Stroke in Patients With and Without Sleep Apnea. Stroke 2005; 36:2614-8. [PMID: 16282549 DOI: 10.1161/01.str.0000189689.65734.a3] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Sleep apnea (SA) is an independent risk factor for arterial hypertension and is present in 50% to 70% of patients with ischemic stroke. The effects of SA on blood pressure (BP) and stroke outcome in the acute stroke phase are essentially unknown.
Methods—
We studied 41 consecutive patients admitted within 96 hours after stroke onset. Stroke severity on admission (National Institutes of Health Stroke Scale [NIHSS]) and stroke outcome at discharge (modified Rankin Disability Scale [mRS]) were assessed. Nocturnal breathing was assessed with an ambulatory device the first night after admission. SA was defined by an apnea-hypopnea-index (AHI) ≥10/hour, and moderate-severe SA (MSSA) was defined by an AHI >30/hour. BP monitoring was performed during the first 36 hours after admission. A nondipping status (NDS) was defined by a ratio >0.9 of mean systolic BP during nights 1 to 2/mean systolic BP during day 2.
Results—
SA was found in 28 (68%) and MSSA in 11 (27%) of 41 patients. A correlation was found between AHI and both NIHSS (
r
=0.331;
P
=0.035) and mRS (
r
=0.341;
P
=0.031). Patients with MSSA had higher systolic and diastolic BP values during night 1 (
P
=0.003), day 2 (
P
=0.004), and night 2 (
P
=0.03). NDS was found in 26 (63%) patients. Nondippers had a similar AHI but higher NIHSS (
P
=0.004) and mRS (
P
=0.005) than dippers. AHI and NDS were confirmed to be independent predictors for both stroke severity and stroke outcome in a multiple stepwise linear regression model.
Conclusions—
SA severity is associated with high 24-hour BP values but only weakly with stroke severity and outcome. Conversely, NDS is linked with a more severe stroke and a poorer evolution but not with SA severity. These data suggest different, although overlapping, pathophysiological and clinical implications of circadian and nocturnal BP values in acute stroke.
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Affiliation(s)
- Claudia Selic
- Neurology Department, University Hospital of Zurich, Zurich, Switzerland
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21
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Wong AA, Davis JP, Schluter PJ, Henderson RD, O'Sullivan JD, Read SJ. The effect of admission physiological variables on 30 day outcome after stroke. J Clin Neurosci 2005; 12:905-10. [PMID: 16257215 DOI: 10.1016/j.jocn.2004.11.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2004] [Accepted: 11/25/2004] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Potentially modifiable physiological variables may influence stroke prognosis but their independence from modifiable factors remains unclear. METHODS Admission physiological measures (blood pressure, heart rate, temperature and blood glucose) and other unmodifiable factors were recorded from patients presenting within 48 hours of stroke. These variables were compared with the outcomes of death and death or dependency at 30 days in multivariate statistical models. RESULTS In the 186 patients included in the study, age, atrial fibrillation and the National Institutes of Health Stroke Score were identified as unmodifiable factors independently associated with death and death or dependency. After adjusting for these factors, none of the physiological variables were independently associated with death, while only diastolic blood pressure (DBP) > or = 90 mmHg was associated with death or dependency at 30 days (p = 0.02). CONCLUSIONS Except for elevated DBP, we found no independent associations between admission physiology and outcome at 30 days in an unselected stroke cohort. Future studies should look for associations in subgroups, or by analysing serial changes in physiology during the early post-stroke period.
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Affiliation(s)
- Andrew A Wong
- Department of Neurology, Royal Brisbane and Women's Hospital, Herston, University of Queensland, St. Lucia, Queensland, Australia.
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22
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Abstract
High blood pressure (BP) is common in acute stroke and might be associated with a poor outcome, although observational studies have given varying results. In a systematic review, articles were sought that reported both admission BP and outcome (death, death or dependency, death or deterioration, stroke recurrence, and hematoma expansion) in acute stroke. Data were analyzed by the Cochrane Review Manager software and are given as odds ratios (ORs) or weighted mean differences (WMDs) with 95% confidence intervals (CIs). Altogether, 32 studies were identified involving 10 892 patients. When all data were included, death was significantly associated with an elevated mean arterial BP ([MABP] OR, 1.61; 95% CI, 1.12 to 2.31) and a high diastolic BP ([DBP] OR, 1.71; 95% CI, 1.33 to 2.48). Combined death or dependency was associated with high systolic BP ([SBP] OR, 2.69; 95% CI, 1.13 to 6.40) and DBP (OR, 4.68; 95% CI, 1.87 to 11.70) in primary intracerebral hemorrhage (PICH). Similarly, high SBP (+11.73 mm Hg; 95% CI, 1.30 to 22.16), MABP (+9.00 mm Hg; 95% CI, 0.92 to 17.08), and DBP (+6.00 mm Hg; 95% CI, 0.19 to 11.81) were associated with death or dependency in ischemic stroke. Combined death or deterioration was associated with a high SBP (OR, 5.57; 95% CI, 1.42 to 21.86) in patients with PICH. In summary, high BP in acute ischemic stroke or PICH is associated with subsequent death, death or dependency, and death or deterioration. Moderate lowering of BP might improve outcome. Acute BP lowering needs to be tested in 1 or more large, randomized trials.
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Affiliation(s)
- Mark Willmot
- Institute of Neuroscience, University of Nottingham, Nottingham, UK
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23
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Vlcek M, Schillinger M, Lang W, Lalouschek W, Bur A, Hirschl MM. Association between course of blood pressure within the first 24 hours and functional recovery after acute ischemic stroke. Ann Emerg Med 2003; 42:619-26. [PMID: 14581913 DOI: 10.1016/s0196-0644(03)00609-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE The relation between course of blood pressure within the first 24 hours after acute stroke and early neurologic outcome remains a matter of dispute. We investigate this relation with adjustment for other influencing variables. METHODS Three hundred seventy-two patients with the diagnosis of ischemic stroke were included to evaluate the relation between blood pressure course and early neurologic outcome. The following data were collected: age; sex; history of hypertension, diabetes mellitus, hyperlipidemia, coronary heart disease, peripheral vascular disease, and stroke; smoking habits; preadmission blood pressure, blood pressure on admission, and blood pressure 24 hours later; antihypertensive treatment; and stroke localization. We assessed outcome at day 5 after admission as dependent or independent (Rankin Scale score <or=2) and applied multivariate logistic regression analysis to investigate the effect of blood pressure changes on outcome, with adjustment for other baseline variables. RESULTS Relative changes of systolic and diastolic blood pressure within hospital admission to 24 hours after admission revealed significant differences of patients' neurologic outcome only for diastolic blood pressure changes from admission to 24 hours. A diastolic blood pressure decrease more than 25% from admission until 24 hours after admission was associated with a 3.8-fold increased adjusted odds (95% confidence interval 1.2 to 12.1) for poor neurologic outcome on day 5 (Rankin Scale score 3 to 5). CONCLUSION Excessive diastolic blood pressure reduction was associated with an increased risk for an impaired neurologic outcome in patients with ischemic stroke. The association between both characteristics was independent from concomitant risk factors, stroke localization, and possible antihypertensive treatment.
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Affiliation(s)
- Marianne Vlcek
- Department of Emergency Medicine, General Hospital, University of Vienna, Vienna, Austria
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24
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Watanabe S, Narita J, Kario K. Two elderly cases of nocturnal onset stroke with stenosis of carotid arteries during the treatment of hypertension. Geriatr Gerontol Int 2002. [DOI: 10.1046/j.1444-1586.2002.00036.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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25
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Fotherby MD, Panayiotou BN. Twenty-four hour blood pressure following stroke. J Intern Med 2002; 251:179-80. [PMID: 11905594 DOI: 10.1046/j.1365-2796.2002.00934.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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