Acute‐phase heart rate trajectories and functional outcomes in acute ischemic stroke

The heart rate (HR) trajectory is a dynamic metric that shows how HR changes over time. Previous studies have demonstrated that elevated HR is associated with stroke events. However, little research has been done on the influence of shifting HR throughout the acute period on clinical outcomes. This study aims to investigate the effect of HR trajectories on functional outcomes in patients with acute ischemic stroke (AIS). A total of 981 AIS patients were included in the study. A latent mixture model was used to assess HR trends over the first 7 days following disease onset. The patients were divided into four groups based on different HR trajectories: markedly decreasing in 48 h (T1), mildly decreasing in 48 h (T2), sustained moderate in 7 days (T3), and sustained high in 7 days (T4). Poor outcome was defined as a modified Rankin Scale (mRS) score of ≥3 in 3 months. Logistic regression was used to analyze the correlation between different HR trajectories and outcomes. The incidence of poor outcomes was 9.02%, 10.80%, 11.79%, 16.36% in T1 (n = 133), T2 (n = 352), T3 (n = 441), and T4 (n = 55) groups, respectively. Compared with T1 group, T4 group was significantly associated with a higher risk of poor outcome at 3 months (odds ratio = 3.00, 95% confidence interval = 1.06–8.54, p value = .0392). This suggests that in AIS patients, a sustained high HR trajectory is linked to a greater likelihood of poor functional outcome than a markedly decreasing HR trajectory. HR trajectories demonstrate the utility of repeated HR measurements for outcome assessment.     

Systolic blood pressure trajectories after acute ischemic strokes and clinical outcomes: A systematic review

Blood pressure(BP) varies drastically during the acute phase after stroke onset. BP level and BP variability may have a major impact on acute ischemic stroke (AIS) prognosis. However, the association between trajectories of blood pressure over time and clinical outcomes have not been established. This review sought out existing evidences for associations of systolic blood pressure (SBP) trajectories on outcomes after stroke to determine the connection between SBP trajectories and stroke prognosis. According to a pre‐designed search strategy, literature search was carried out in Embase, Pubmed and Web of Science. Two authors independently evaluated study eligibility and quality, and literature data were extracted. When the literature was eligible, we perform meta‐analysis to determine associations of SBP trajectories with clinical outcomes. Seven studies were finally screened out of 52 studies retrieved. Seven studies received a good risk of bias rating and reported BP measurement methods and intervals, BP trajectories modeling methods, outcome measures, but it was found that final systolic BP trajectories in various papers were significantly different. All studies reported statistically significant associations between systolic blood pressure trajectories and prognosis. Methodological heterogeneity is observed in studies. However, this systematic review suggests that the high SBP group after AIS is related to poor clinical outcomes, while the rapid decline or medium‐to‐low or low SBP group is associated with relatively better clinical outcomes at different period after stroke. More prospective studies are needed to report the full methodology according to standardized criteria and explore relationships between SBP trajectories and prognosis of stroke.     

Ambulatory blood pressure variability within the first 24 hours after admission and outcomes of acute ischemic stroke

Our purpose was to evaluate the value of blood pressure variability within the first 24 hours after admission in predicting outcomes of patients with acute ischemic stroke (AIS). A greater variability in systolic blood pressure (adjusted odds ratio [OR] = 1.801, 95% confidence interval [CI] = 1.167–2.779) was associated with poor discharge outcome, especially for nondiabetics (adjusted OR = 1.948, 95% CI = 1.184–3.205) and cardioembolism-related patients with AIS (OR = 7.650, 95% CI = 1.370–42.713). However, this correlation was not observed with a long-term (3-month or 6-month) outcome in patients with AIS. There was no association between diastolic blood pressure variability within the first 24 hours after admission and outcome. In conclusion, systolic blood pressure variability within the first 24 hours after admission is a critical predictor for short-term outcome of patients with AIS.     

Acute in‐hospital blood pressure variability predicts early neurological deterioration in acute minor stroke or transient ischemic attack with steno‐occlusive arterial disease

It is generally known that acute minor stroke and transient ischemic attack (TIA) seem to be benign. However, their occurrence in patients with steno‐occlusive arterial disease may result in early neurological deterioration (END). We aimed to elucidate the effect of blood pressure variability (BPV) on the development of END. Consecutive acute minor stroke and TIA patients within 24 hours of onset were prospectively recruited from the Affiliated Hospital of Yangzhou University between Aug 2015 and Feb 2019. END was defined as an NIHSS score increased ≥1 during the first 72 hours compared with the initial NIHSS score. During this period, the mean, maximum (max), the difference between the maximum and minimum (max‐min), the SD, and coefficient of variation of BP (BP_CV) were calculated. Of the 160 total patients enrolled in the study (mean age, 68.01 ± 9.33 years; 50.6% female), 52 (32.5%) patients occurred END during the first 72h after admission. To express the BPV as a categorical variable, we classified the subjects into one of four groups, representing four quartiles of BPV. In the multivariable analyses, the lowest quartiles were considered as reference groups. The results showed that patients who fell in the fourth quartile (SBP_max‐min:OR = 3.289, 95% CI 1.147‐9.430; SBP_SD:OR = 3.313, 95% CI 1.041‐10.547; SBP_CV:OR = 3.425, 95% CI 1.164‐10.077; DBP_SD:OR = 3.124, 95% CI 1.065‐9.158) had a significantly higher risk of END after adjusting the variables (age, female, diabetes mellitus, atrial fibrillation, and CRP with P values <.1 in univariate analyses). Our study demonstrated that the acute in‐hospital BPV was associated with the development of END in acute minor stroke and TIA with steno‐occlusive arterial disease.     

急性缺血性卒中患者的血压管理

急性缺血性卒中患者在发病最初24 h内一般会出现血压增高,且血压水平与患者预后相关.在缺血性卒中急性期的血压管理中,无论是试图升压或是降压治疗都存在争议.文章综述了缺血性卒中急性期血压变化以及血压管理与卒中预后的关系.     

A retrospective study of Yiqi-Huoxue Decoction on blood pressure in patients with acute ischemic stroke

This retrospective study investigated the effect of Yiqi-Huoxue Decoction (YQHXD) on blood pressure (BP) in patients with acute ischemic stroke (AIS).A total of 72 patients with BP following AIS who received routine treatment were included in this retrospective study. Of those, 36 patients received YQHXD and were assigned to a treatment group. The other 36 patients were allocated to a control group. All patients were treated for a total of 4 months. The outcomes were assessed by systolic blood pressure (SBP), diastolic blood pressure (DBP), National Institutes of Health Stroke Scale (NIHSS) score and Barthel index scale (BIS). All outcomes were measured after 4-month treatment.After treatment, all subjects in the treatment group showed greater improvements in SBP (P < .05), DBP (P < .05), NIHSS (P < .05) score, and BIS (P < .05) than those of patients in the control group. In addition, the safety profile is similar in both groups.The findings of this study demonstrated that YQHXD may benefit on BP in patients with AIS. Future studies should focus on warranting the current results.     

随诊间血压变异性对脑卒中复发的影响

目的探讨随诊间血压变异性对脑卒中复发的影响。方法回顾性分析12所医院进行的西洛他唑和阿司匹林预防脑卒中复发试验中698例患者的每次随诊血压,通过Cox比例风险回归模型,计算随诊间血压变异性对脑卒中复发影响的风险比。结果随诊间收缩压标准差与平均收缩压相关(r=0.282,P=0.000),变异系数与平均收缩压相关(r=0.128,P=0.001);调整平均收缩压后,收缩压标准差HR:3.641,95%CI:2.368⁵.599,收缩压变异系数HR:3.327,95%CI:2.1305.599,收缩压变异系数HR:3.327,95%CI:2.130⁵.195,收缩压独立均值变异(VIM)HR:3.657,95%CI:2.3205.195,收缩压独立均值变异(VIM)HR:3.657,95%CI:2.320⁵.763,差异有统计学意义(P=0.000)。平均舒张压HR:4.149,95%CI:2.3815.763,差异有统计学意义(P=0.000)。平均舒张压HR:4.149,95%CI:2.381⁷.229(P=0.000),舒张压标准差、舒张压变异系数、舒张压VIM差异无统计学意义(P>0.05)。调整平均脉压后,脉压标准差HR:4.973,95%CI:3.2957.229(P=0.000),舒张压标准差、舒张压变异系数、舒张压VIM差异无统计学意义(P>0.05)。调整平均脉压后,脉压标准差HR:4.973,95%CI:3.295⁷.506,脉压变异系数HR:6.410,95%:CI::3.8987.506,脉压变异系数HR:6.410,95%:CI::3.898¹0.538,差异有统计学意义(P=0.000)。结论随诊间收缩压和脉压变异性均是影响脑卒中复发的因素;但随诊间舒张压变异性不是影响脑卒中复发的因素。     

Predicting prognosis in patients with stroke treated with intravenous alteplase through the 24‐h trajectory of blood pressure changes

Blood pressure (BP) monitored within 24 h from the beginning of intravenous thrombolysis (IVT) with alteplase, is one of the important factors affecting the prognosis of patients with acute ischemic stroke (AIS). This study aimed to explore longitudinal BP trajectory patterns and determine their association with stroke prognosis after thrombolysis. From November 2018 to September 2019, a total of 391 patients were enrolled consecutively during the study period, and 353 patients were ultimately analyzed. Five systolic (SBP) and four diastolic blood pressure (DBP) trajectory subgroups were identified. The regression analysis showed that when compared with the rapidly moderate stable group, the continuous fluctuation‐very high level SBP group (odds ratio [OR]: 2.743, 95% confidence interval [CI]: 1.008–7.467) was associated with early neurological deterioration (END). Both the rapid drop‐high level SBP (OR: 0.448, 95% CI: 0.219–0.919) and DBP groups (OR: 0.399, 95% CI: 0.219–0.727) were associated with early neurological improvement (ENI). Moreover, there was a U‐shaped correlation between the OR value of SBP trajectory group and favorable outcome (the modified Rankin Scale [mRS] score 0–2) at 3 months: the slow drop‐low level SBP group represent a well‐established unfavorable outcome risk factor (OR:5.239, 95% CI: 1.271–21.595), and extremely high SBP—the continuous fluctuation‐very high level SBP group, are equally associated with elevated unfavorable outcome risk (OR:3.797, 95% CI: 1.486–9.697). The continuous fluctuation‐very high level DBP group was statistically significant in mRS (OR: 3.387, CI: 1.185–9.683). The BP trajectory groups show varying clinical features and risk of neurological dysfunction. The findings may help identify potential candidates for clinical BP monitoring, control, and specialized care.     

血压变异性与缺血性卒中静脉溶栓后发生症状性颅内出血的相关性研究

目的探讨早期血压变异性(BPV)预测急性缺血性卒中(AIS)静脉溶栓(IVT)后发生症状性颅内出血(s ICH)风险的价值。方法纳入2012至2016年的发病4.5 h内行重组组织型纤溶酶原激活剂IVT且临床资料完整的AIS患者。依据溶栓治疗后48 h内头颅CT或MRI结果及NIHSS评分变化分为s ICH组(22例)和非s ICH组(157例)。采用单因素t、χ2检验和多因素Logistic回归分析2组s ICH危险因素的差异性。进一步分别将24 h收缩压标准差(24hSBPsd)和24h舒张压标准差(24hDBPsd)以四分位数分为4组,以最低四分位组为参照组,其余组分别与参照组比较。结果单因素分析表明,s ICH组年龄、纤维蛋白原(FIB)、吸烟史、24hSBPsd、24hDBPsd均高于非s ICH组(均P0.05)。多因素Logistic回归分析表明,s ICH组年龄(OR 3.117,95%CI 1.089～8.920)、吸烟史(OR 2.933,95%CI 1.042～8.257)及24hSBPsd(OR 4.135,95%CI 1.397～12.237)均仍高于非s ICH组(均P0.05),而2组之间FIB、24hDBPsd比较,差异无统计学意义(P0.05)。校正年龄、吸烟史危险因素后,最高四分组24hSBPsd、24hDBPsd发生s ICH风险分别是最低四分位组的10. 882倍(95%CI 2. 088～56. 717)、6. 025倍(95%CI 1. 550～23.417),差异均有统计学意义(P0.05)。结论早期BPV越大,发生IVT后s ICH风险越高,以收缩压变异性的影响更明显。     

Evaluation of the association between admission systolic blood pressure and the choice of initial antiplatelet therapy for minor ischemic stroke in real‐world

To evaluate whether admission systolic blood pressure (SBP) is associated with the choice of initial antiplatelet therapy for minor stroke. Eligible patients retrospectively gathered from 2010 to 2018. Finally, 1312 of 1494 patients were divided into three groups: aspirin monotherapy (AM, n = 538, 41.0%), dual antiplatelet therapy with aspirin and load‐clopidogrel (clopidogrel loading dose of 300 mg on the first day, DAPT‐ALC, n = 474, 35.6%), and dual antiplatelet therapy with aspirin and unload‐clopidogrel (clopidogrel 75 mg daily with no loading dose, DAPT‐AUC, n = 300, 22.9%). The mean ± SD age of final patients was 62.0 ± 12.7 years old; 903 (70.9%) participants were male. Patients in the DAPT‐ALC group were more likely to be younger, to arrive earlier, and to have a lower proportion of intracerebral hemorrhage than those in the AM group. DAPT‐AUC group patients were more like to have a history of acute myocardial infarction and less likely to have a history of ICH than the AM group (4.7% vs. 1.7% and .3% vs. 2.6%, p < .05). Overall, there was a likely “S‐shaped” association between the selection of the DAPT‐ALC or DAPT‐AUC scheme and admission systolic blood pressure (P for nonlinearity = .012). Compared with the SBP < 140 mmHg group, the SBP ≥ 180 mmHg group was more likely to be given DAPT‐AUC (OR = 2.92 [1.62–5.26], p < .001) than DAPT‐ALC. Our findings support that admission SBP is associated with the choice of initial antiplatelet, especially when the SBP was greater than or equal to 180 mmHg.     

Blood pressure level and outcomes in adults aged 65 and older with prior ischemic stroke

OBJECTIVES: To examine the association between blood pressure (BP) levels and long-term stroke outcomes in elderly stroke survivors. DESIGN: Observational study. SETTING: The Cardiovascular Health Study (CHS) of 5,888 community-dwelling adults. PARTICIPANTS: Two hundred fifty-four adults aged 65 and older (mean age 78.6) who sustained a nonfatal first ischemic stroke. MEASUREMENTS: BP levels assessed at prestroke and poststroke CHS visits were examined as predictors of stroke recurrence, coronary heart disease (CHD), combined vascular events (CVEs), and mortality. RESULTS: Higher poststroke BP level, assessed 261.6 days (mean) after stroke, was associated with higher risk of stroke recurrence over 5.4 years (mean) of follow-up. The multivariate-adjusted hazard ratio for stroke recurrence was 1.42 (95% confidence interval (CI) = 1.03-1.99) per standard deviation (SD) of systolic BP (P = .04) and 1.39 (95% CI = 1.01-1.91) per SD of diastolic BP (P = .04). Mortality was significantly greater in patients with low or high poststroke BP than in those with intermediate BP. Poststroke BP was not associated with risk of CHD or CVE, although further analyses suggested that high systolic BP predicted CHD and CVE in younger but not older subjects. Prestroke BP did not predict poststroke outcomes. CONCLUSION: In this observational study of adults aged 65 and older assessed approximately 8 months after stroke, low BP was associated with favorable risk of recurrent stroke, although high and low poststroke BP levels were associated with greater mortality. Long-term antihypertensive trials in older stroke survivors would increase knowledge about the benefits of lowering BP in this population.     

Blood pressure variability at different time periods within first 24 hours after admission and outcomes of acute ischemic stroke

This study discusses the association between blood pressure (BP) variability at different time periods within first 24 hours after admission and the functional outcome in acute ischemic stroke (AIS). We observed BP variability within first 24 hours after admission and evaluated the association between BP variability at different time periods (4 am ‐8 am , 10 am ‐2 pm , 4 pm ‐8 pm , 10 pm ‐2 am ) and the functional outcome in AIS. National Institute of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) were applied to evaluate short‐ (7 days) and long‐term functional outcome. The 24 hours after admission and early morning (4 am ‐8 am ) systolic blood pressure (SBP) variability were associated with poor outcome at day 7 (adjusted OR = 1.567, 95% CI = 1.076‐2.282; adjusted OR = 1.507, 95% CI = 1.028‐2.209, respectively). Compared with the impact of the 24‐hour BP variability on long‐term functional outcome, the early morning SBP was proved to be a strongly independent predictor for functional outcome at 3 months (adjusted OR = 1.505, 95% CI = 1.053‐2.152), 6 months (adjusted OR = 1.560, 95% CI = 1.048‐2.226), and 12 months (adjusted OR = 1.689, 95% CI = 1.104‐2.584). The BP variability in other time period groups was shown to have no influence on functional outcome. In addition, attempts to explain early morning BP variability with baseline characteristic factors at admission found that baseline SBP is the most influential (2.71%) factor. About 95.87% of the SBP variability in early morning was unexplained. In our study, early morning SBP variability is the strongest independent predictor for functional outcome in (AIS) patients, and baseline SBP after admission should be monitored as a control indicator of early morning SBP variability in the treatment of AIS patients.     

动态心电图和动态血压同步监测在缺血性脑卒中患者诊断中的临床价值

目的探讨动态心电图和动态血压同步监测在缺血性脑卒中(ischemic stroke,IS)患者诊断中的临床价值。方法选择2016年12月至2018年11月酒泉市金塔县人民医院接诊的46例IS患者进行研究,设定为IS组,并选取同期在我院进行检查的原发性高血压(高血压)患者32例,设定为无IS组(non-ischemic stroke,NIS)组。对所有患者进行动态心电图(dynamic electrocardiogram,DCG)和动态血压(ambulatory blood pressure,ABP)同步监测。比较两组患者昼夜血压变化、异常心电图比例和心率变异性相关指标,对相关参数进行Logistic多因素回归分析。结果与NIS组相比,IS组患者昼夜平均收缩压和血压昼夜节律消失比例均显著升高,日间平均舒张压显著降低,差异有统计学意义(P<0.05)。IS组DCG监测到房性期前收缩、房性心动过速、短阵心房颤动、室性期前收缩和ST段改变的比例明显高于NIS组,差异有统计学意义(P<0.05)。IS组在窦性R-R间期标准差(standard deviation of normal R-R intervals,SDNN)、窦性R-R间期差值的平方根(root mean square of the successive normal sinus R-R interval difference,rMSSD)和每5 min时段窦性R-R间期平均值标准差(standard deviation of the averaged normal sinus R-R intervals for all 5-minute segments over 24 hours,SDANN)等心率变异性指标上明显低于NIS组,差异有统计学意义(P<0.05)。Logistic多因素回归分析显示昼夜平均收缩压、血压昼夜节律消失、心房颤动与IS呈正相关,日间平均舒张压、SDNN、rMSSD、SDANN与IS呈负相关。结论血压昼夜节律消失、心律失常、心率变异与IS发生关系密切,同步监测高血压患者DCG和ABP对预诊断IS具有较高的临床价值。     

Very high blood pressure in acute stroke

In a study sample consisting of 388 unselected, consecutive acute stroke patients, 27 with systolic blood pressure greater than or equal to 200 mmHg and diastolic blood pressure greater than or equal to 115 mmHg were compared with the other 361 patients. The patients with high blood pressure were younger (65 vs. 73 years) and much more often had a history of hypertension (78 vs. 42%). Cardiac and vascular hypertensive manifestations were more frequent, particularly when only those patients with a history of hypertension were compared in the two groups. Alcohol abuse was mentioned in a higher proportion of hypertensives in the summaries of their medical records. No definite conclusions could be drawn with regard to the size and location of the brain lesions. Clinical symptoms did not differ between the groups, neither did the proportion of patients who could be discharged from hospital immediately. Mortality was higher in the high blood pressure group (30 vs. 14%, P less than 0.05). Thus the characteristics of patients with very high blood pressure were: younger age, much more frequent and severe previous hypertension. Alcohol abuse might be an important factor. The type, size and location of the brain lesion itself could not be statistically related to the high blood pressure, but very large lesions, particularly haemorrhages, might be associated with a reactive blood pressure response.     

急性缺血性卒中合并心脏病患者血压管理专家共识

急性缺血性卒中的血压管理不同于陈旧缺血性卒中的血压管理。当急性缺血性卒中合并心脏病(如急性心肌梗死或心力衰竭等)时,对于血压管理的要求就变得更加复杂。本共识围绕急性缺血性卒中合并急慢性冠状动脉综合征、合并心力衰竭等临床复杂情况,对降压时机、降压目标、降压用药及处置流程等进行专家意见的总结。     

Cancer‐associated ischemic stroke is associated with elevated d‐dimer and fibrin degradation product levels in acute ischemic stroke with advanced cancer

Aim: Although several studies have reported various causes of ischemic stroke in patients with cancer, only a few have evaluated the clinical relevance of ischemic stroke pathogenesis to cancer. The aim of the present study was to elucidate the clinical characteristics of cancer‐associated ischemic stroke. Methods: We evaluated 154 ischemic stroke patients without cancer and 57 ischemic stroke patients with cancer who had either received continuous treatment for cancer within 5 years before to the onset of ischemic stroke, or who had been diagnosed with cancer within 1 year after the onset of ischemic stroke. Cancer patients were grouped into “cancer‐associated ischemic stroke,” the “conventional ischemic stroke,” or “other.” Results: A total of 15 patients (26%) were classified into the cancer‐associated ischemic stroke in cancer patients. In univariate analysis of the cancer‐associated ischemic stroke and the others, there were significant differences in the prevalence of hypertension, hyperlipidemia and advanced cancer (clinical stage IV), and the levels of d ‐dimer, fibrin degradation product and hemoglobin. With multivariate regression analysis of those factors, the prevalence of hypertension, hyperlipidemia and advanced cancer (clinical stage IV), and the levels of d ‐dimer and fibrin degradation product remained as statistically independent factors, which were associated with cancer‐associated ischemic stroke (n = 111, χ² = 67.21, P < 0.0001). Conclusion: In acute ischemic stroke, the cancer‐associated ischemic stroke is associated with elevated d ‐dimer and fibrin degradation products, even after controlling hypertension, hyperlipidemia and advanced cancer (clinical stage IV). Geriatr Gerontol Int 2012; 12: 468–474.