Effects of Early-Stage Blood Pressure Variability on the Functional Outcome in Acute Ischemic Stroke Patients With Symptomatic Intracranial Artery Stenosis or Occlusion Receiving Intravenous Thrombolysis

Effect of blood pressure variability on the outcomes of acute ischemic stroke patients undergoing intravenous thrombolysis

BACKGROUND

There is limited research on the relationship between blood pressure variability (BPV) and outcomes among patients receiving intravenous thrombolysis (IVT) for acute ischemic stroke (AIS). This study aimed to investigate the effect of 24-h BPV on the outcome of patients with AIS treated with IVT.

METHODS

A retrospective analysis was conducted on clinical data of patients with AIS who had undergone IVT treatment. During the initial 24 h after IVT, various BPV parameters for systolic and diastolic blood pressure were calculated, including the maximum BP, minimum BP, mean BP, standard deviation, coefficient of variation, and average real variability (ARV). Follow-up was conducted at 90 days post-onset, with outcomes classified as "good" or "poor" based on a modified Rankin Scale score of ≤2 or >2, respectively.

RESULTS

A total of 216 patients were included in the study and divided into two groups based on their outcomes: a good-outcome group (n = 151, 69.9 %) and a poor-outcome group (n = 65, 30.1 %). A comparison of the poor-outcome group with the other group revealed significant differences in age, baseline National Institutes of Health Stroke Scale, Trial of Org 10172 in Acute Stroke Treatment classification, diabetes mellitus, and atrial fibrillation (P < 0.05). The maximum systolic blood pressure (163.58 ± 19.76 vs. 173.91 ± 18.51 mmHg) and average rate of ventricular response (10.35 vs. 12.09) in the good-outcome group were lower than those in the poor-outcome group (all P < 0.05). After adjusting for confounding factors in the binary logistic regression analysis, the maximum systolic blood pressure (odds ratio = 1.023, 95 % confidence interval = 1.004-1.043, P = 0.019] and ARV (odds ratio = 1.103, 95 % confidence interval = 1.007-1.208, P = 0.035) were significantly associated with adverse outcomes.

CONCLUSION

The maximum systolic blood pressure and mean true variation rate were negatively correlated with outcomes.

Assessment of Blood Pressure and Heart Rate Related Variables in Acute Stroke Patients Receiving Intravenous Antihypertensive Medication Infusions

BACKGROUND

We performed an analysis of a large intensive care unit electronic database to provide preliminary estimates of various blood pressure parameters in patients with acute stroke receiving intravenous (IV) antihypertensive medication and determine the relationship with in-hospital outcomes.

METHODS

We identified the relationship between pre-treatment and post-treatment systolic blood pressure (SBP) and heart rate (HR)-related variables and in-hospital mortality and acute kidney injury in patients with acute stroke receiving IV clevidipine, nicardipine, or nitroprusside using data provided in the Medical Information Mart for Intensive Care (MIMIC) IV database.

RESULTS

A total of 1830 patients were treated with IV clevidipine (n = 64), nicardipine (n = 1623), or nitroprusside (n = 143). The standard deviations [SDs] of pre-treatment SBP (16.3 vs. 13.7, p ≤ 0.001) and post-treatment SBP (15.4 vs. 14.4, p = 0.004) were higher in patients who died compared with those who survived, particularly in patients with intracerebral hemorrhage (ICH). The mean SBP was significantly lower post treatment compared with pre-treatment values for clevidipine (130.7 mm Hg vs. 142.5 mm Hg, p = 0.006), nicardipine (132.8 mm Hg vs. 141.6 mm Hg, p ≤ 0.001), and nitroprusside (126.2 mm Hg vs. 139.6 mm Hg, p ≤ 0.001). There were no differences in mean SDs post treatment compared with pre-treatment values for clevidipine (14.5 vs. 13.5, p = 0.407), nicardipine (14.2 vs. 14.6, p = 0.142), and nitroprusside (14.8 vs. 14.8, p = 0.997). The SDs of pre-treatment and post-treatment SBP were not significantly different in patients with ischemic stroke treated with IV clevidipine, nicardipine, or nitroprusside or for patients with ICH treated with IV clevidipine or nitroprusside. However, patients with ICH treated with IV nicardipine had a significantly higher SD of post-treatment SBP (13.1 vs. 14.2, p = 0.0032).

CONCLUSIONS

We found that SBP fluctuations were associated with in-hospital mortality in patients with acute stroke. IV antihypertensive medication reduced SBP but did not reduce SBP fluctuations in this observational study. Our results highlight the need for optimizing therapeutic interventions to reduce SBP fluctuations in patients with acute stroke.

Association between 24-hour blood pressure parameters and 90-day functional outcome in acute ischemic stroke patients with early anticoagulation

This study aimed to examine the relationship between blood pressure (BP) and blood pressure variability (BPV) during the first 24 hours from admission with 90-day functional outcomes in acute ischemic stroke (AIS) patients whose onset within 24 hours and receiving early argatroban treatment. The study recruited 214 AIS patients. BP was monitored using a cuff at 1-hour fixed intervals, and BP/BPV parameters [standard deviation (SD), coefficient of variation (CV), successive variation (SV), and average real variability (ARV)] were collected. Age, the National Institutes of Health Stroke Scale (NIHSS) score at admission, previous history of diabetes mellitus (DM), and infarction site (located in anterior circulation) were identified as independent factors affecting 90-day outcomes in multiple logistic regression. After adjusting for confounding variables, association between BP/BPV and 90-day modified Rankin Scale (mRS) was assessed using logistic regression models. In model 1 (adjusted for age and NIHSS score at admission), mean-systolic blood pressure (SBP) showed association with 90-day outcomes [1.068 (1.008, 1.131), P = .025]. In model 2 (adjusted for age, NIHSS score at admission, previous history of DM), mean-SBP [1.061 (1.001, 1.123), P = .045] and max-SBP [0.951 (0.906, 0.998), P = .040] showed relatively weak association with outcomes. In model 3 [adjusted for age, NIHSS score at admission, previous history of DM, infarct site (located in anterior circulation)], all BP values were not related with outcomes, meanwhile, none of the BPV parameters calculated from SBP, diastolic blood pressure and mean arterial pressure showed association with 90-day outcomes. Future prospective studies are required to assess the relationship between early BP/BPV parameters with 90-day outcomes and further clarify the reference values for BP parameters. This is important for effective BP/BPV management and improved patient prognosis.

Early vs Delayed Antihypertensive Treatment in Acute Single Subcortical Infarction: A Secondary Analysis of the CATIS-2 Randomized Clinical Trial

Importance

The China Antihypertensive Trial in Acute Ischemic Stroke II (CATIS-2) suggests that early antihypertensive treatment did not reduce the risk of dependency or death in acute ischemic stroke (AIS), compared with delayed treatment. Single subcortical infarction (SSI) is an important stroke subtype, and the association of antihypertensive timing with clinical outcomes is unclear.

Objective

To investigate the association of early vs delayed antihypertensive treatment with clinical outcomes in patients with SSI, stratified by the presence of parent artery disease (PAD) stenosis.

Design, Setting, and Participants

This secondary analysis of the CATIS-2 randomized clinical trial included 106 hospitals in China between June 2018 and July 2022. In CATIS-2, patients with AIS within 24 to 48 hours of symptoms onset and elevated systolic blood pressure were eligible. Patients with SSI detected in diffusion-weighted imaging were included in the current post hoc subgroup analysis. Patients were grouped into (1) SSI with PAD stenosis and (2) SSI without PAD stenosis. Statistical analysis was performed from July 2023 to May 2024.

Exposures

Early (immediate) vs delayed (starting on day 8) antihypertensive therapy.

Main Outcome and Measure

Primary outcome was the combination of functional dependency or death (modified Rankin Scale score ≥3) at 90 days.

Results

Among 997 patients with SSI in CATIS-2 (mean [SD] age, 62.4 [9.8] years; 612 [61.4%] men), 116 (11.6%) had SSI with PAD and 881 (88.4%) had SSI without PAD. There was no significant difference in the primary outcome between early and delayed antihypertensive treatment groups among all patients with SSI (8.8% vs 7.1%; OR, 1.25 [95% CI, 0.79-1.99]; P = .34). Among patients with SSI with PAD, early antihypertensive treatment was associated with increased risk of the primary outcome compared with delayed treatment (23.4% vs 7.7%; OR, 3.67 [95% CI, 1.14-11.86]; P = .03); this finding was not observed in patients with SSI without PAD (6.6% vs 7.1%; OR, 0.93 [95% CI, 0.55-1.57]; P = .77). Significant interaction with treatment and presence of PAD stenosis was detected for the primary outcome (P for interaction = .04).

Conclusions and Relevance

In this secondary analysis of a randomized clinical trial, early antihypertensive treatment was associated with an increased risk of functional dependency or death at 90 days among patients with SSI and coexisting PAD stenosis, compared with delayed antihypertensive treatment. Further studies are warranted for individualized BP management in patients with SSI by the presence of PAD.

Trial Registration

ClinicalTrials.gov Identifier: NCT03479554.

Blood Pressure Variability in Acute Stroke: A Narrative Review

The management of blood pressure variability (BPV) in acute stroke presents a complex challenge with profound implications for patient outcomes. This narrative review examines the role of BPV across various stages of acute stroke care, highlighting its impact on treatment strategies and prognostic considerations. In the prehospital setting, while guidelines lack specific recommendations for BP management, emerging evidence suggests a potential link between BPV and outcomes. Among ischaemic stroke patients who are ineligible for reperfusion therapies, BPV independently influences functional outcomes, emphasising the need for individualised approaches to BP control. During intravenous thrombolysis and endovascular therapy, the intricate interplay between BP levels, recanalisation status, and BPV is evident. Striking a balance between aggressive BP lowering and avoiding hypoperfusion-related complications is essential. Intracerebral haemorrhage management is further complicated by BPV, which emerges as a predictor of mortality and disability, necessitating nuanced BP management strategies. Finally, among patients with acute subarachnoid haemorrhage, increased BPV may be correlated with a rebleeding risk and worse outcomes, emphasizing the need for BPV monitoring in this population. Integration of BPV assessment into clinical practice and research protocols is crucial for refining treatment strategies that are tailored to individual patient needs. Future studies should explore novel interventions targeting BPV modulation to optimise stroke care outcomes.

Blood pressure excursion on admission and intravenous thrombolysis in ischemic stroke

BACKGROUND

Blood pressure (BP) excursion on admission was common in patients with acute ischemic stroke, but its influence on thrombolysis effect was not fully evaluated.

METHODS

Patients with acute ischemic stroke who received thrombolysis without subsequent thrombectomy were included. Admission BP excursion was defined as higher than 185/110 mmHg. Multivariate logistic regression analysis was used to evaluate the relationship between admission BP excursion and poor outcome as well as hemorrhage rates and mortality. Poor outcome was defined as a 90-day modified Rankin Scale score 3-6. Subgroup analysis was performed according to stroke severity, which was assessed by the National Institutes of Health Stroke Scale (NIHSS) score, and hypertension status.

RESULTS

A total of 633 patients were enrolled and 240 participants (37.9%) had admission BP excursion. Admission BP excursion was associated with poor outcome [adjusted odds ratio (OR) 0.64, 95% confidence interval 0.42-0.99, P  = 0.046]. No significant difference was found regarding hemorrhage rates or mortality between patients with and without admission BP excursion. In subgroup analysis, admission BP excursion was related to poor outcome in patients with NIHSS score at least 7 (adjusted OR 1.89, 95% confidence interval 1.03-3.45, P  = 0.038), but not in patients with NIHSS score less than 7 ( P for interaction <0.001).

CONCLUSION

Admission BP excursion above the guideline thresholds did not increase postthrombolysis hemorrhage risk or mortality, but was associated with poor outcome, especially in patients with severe stroke.