卒中急性期血压管理的研究现状

高血压为卒中的独立危险因素,适当降低血压是卒中一级和二级预防的重要组成部分[1].血压升高是卒中急性期的常见并发症,与预后不良相关.由于缺乏确切的临床试验证据,卒中急性期血压水平与临床预后的相关性及血压控制原则目前仍未达成一致意见[2].国际高血压协会对此提出了3个尚待解决的问题[3]:急性缺血性卒中患者血压升高时是否需要降压治疗;无高血压者是否应在不增加出血风险的前提下行升压治疗以改善缺血区的血流灌注?原发性脑出血急性期的患者是否需要降压治疗?长期降压治疗的患者,急性卒中后应继续使用还是停用降压药物?我们综述卒中急性期血压变化及血压管理的研究,并总结目前卒中急性期的血压治疗指南.     

卒中患者血压水平与卒中后认知障碍关系的研究进展

卒中后认知障碍为卒中的常见并发症之一,可严重影响卒中患者的生活质量及预后。目前认为血压与卒中后认知障碍密切相关,血压可能对卒中后认知障碍的主要病理生理过程产生潜在影响,并且控制血压可能有助于卒中后认知障碍的改善或预防。血压与卒中后认知障碍之间的相关性较为复杂,可能取决于特定的血压参数和卒中的不同阶段。目前卒中后的最佳血压控制水平尚不统一。本文对卒中后认知障碍的流行病学,血压与卒中后认知障碍的相关性,血压影响卒中后认知障碍的相关机制,以及控制血压的作用进行综述,为进一步阐明卒中后认知障碍的病理生理过程提供重要依据,以期有助于指导临床治疗,从而改善卒中患者的预后。     

脑卒中急性期血压变化临床研究

采用前瞻性研究方法，对１３８例急性脑卒中患者及１２６例非卒中患者的血压变化规律进行了连续７天动态观察；并对其中８０例卒中患者进行６个月的随访。结果：卒中组与对照组入院后血压均以首次测量的为最高，此后在无特殊降压措施下，脑卒中组血压迅速下降，４天内达低值，以后血压在此水平上下波动。卒中后首次测量血压显著升高者６月后神经功能恢复较差，但与近期死亡率无明显相关性。故对卒中急性期升高的血压应采取慎重态度，避免在此期急骤降低血压。     

JAMA N：卒中二级预防的血压目标应小于130/80 mm Hg?

2010年,全世界首次卒中的绝对人数为1690万,卒中相关死亡人数为590万,因此,卒中的一级和二级预防应优先考虑。血压升高是卒中最相关、最常见的危险因素,降压治疗是卒中一级和二级预防最有效的方法。在心血管事件(包括卒中)的一级预防试验中,高血压患者血压控制越低,卒中预防效果越好,并且有研究发现血压<115 m m Hg是最佳的收缩压目标水平。培哚普利预防复发性卒中研究(Perindopril Protection Against Recurrent Stroke Study,PROGRESS)显示,无论是否存在高血压,卒中慢性期降压治疗能够降低复发性卒中风险。     

急性脑梗塞和脑出血中血压的变化

由于能提供有关卒各种亚型急性期血压变化精确数据的研究资料较少,所以目前对于急性卒中后血压的升高是否应该治疗仍有争议。本研究通过对刚入院和入院后7天各种类型卒中病人及住院对照组病人的24小时血压进行记录,来研究不同类型急性卒中病人入院后血压的变化。     

卒中急性期血压的变化规律及影响因素研究

目的观察卒中急性期的血压变化规律以及影响血压变化规律的因素。方法研究入院距发病时间〈24h的急性脑梗死及脑出血的住院病人,进行基本数据收集,监测入院后7d内血压变化,对病程中伴发疾病进行评分,对入院后血压管理的方式及干预时间进行登记。结果（1）卒中急性期初期血压通常升高,入院后16h内血压下降较明显,前4h尤甚,16～48h血压逐渐平稳,各时点血压经方差分析无显著性差异;（2）脑出血患者的急性期血压较脑梗死患者的急性期血压高,P〈0.05;（3）TOAST各亚型脑梗死血压变化规律无明显差异;（4）原有高血压史的患者卒中后急性期血压较既往无高血压史的患者高;（5）经多因素相关分析,影响卒中急性期7d内平均收缩压的正相关因素有卒中类型、高血压史、伴发病评分;影响卒中急性期7d内平均舒张压的正相关因素有卒中类型、高血压史、伴发病评分,既往病史评分与卒中急性期7d内平均舒张压呈负相关。结论卒中急性期初期血压通常升高,脑出血、既往有高血压史、合并疾病多的卒中患者卒中后血压较高,入院后16h内血压下降较明显,入院后16～48h血压渐趋平稳。     

不同类型急性卒中入院首次血压的观察

目的探讨不同类型急性卒中患者入院首次血压各指标的状况。方法对59例脑梗死、42例脑出血患者及30例体检人员的收缩压（SBP）、舒张压（DBP）进行测量，并计算脉压（PP）、平均血压（MBP），并与神经功能损害分级进行相关性分析。结果SBP、DBP、PP、MBP各值在脑梗死组、脑出血组均显著高于对照组，脑梗死组与脑出血组比较除PP值外，SBP、DBP、MBP后者均高于前者（P〈0．05），SBP、DBP、PP、MBP无论在脑梗死组还是脑出血组，均与神经功能损害分级不相关。结论急性卒中患者入院首次血压各成份均显著高于健康体检者；急性卒中中，入院首次血压的SBP、DBP、MBP在脑出血组比脑梗死组更高；无论是脑梗死还是脑出血，入院首次血压各成份与神经损害的程度不相关。     

急性缺血性卒中血压调控研究进展

高血压是缺血性卒中的独立危险因素,缺血性卒中患者血压的管理直接影响患者的预后,但目前缺血性卒中急性期的血压管理存在许多争议。本文主要介绍血压管理对缺血性卒中的影响及急性期血压调控的争论,重点探讨国际国内相关研究的结论及今后的研究方向,明确缺血性卒中急性期血压调控对临床的指导意义。     

急性腔隙性卒中患者血压的变异性及节律与脑白质高信号的相关性研究

目的 探索急性腔隙性卒中患者脑白质高信号与血压变异性及血压节律的关联。方法 回顾性纳入2017年1月-2019年1月于武汉市中西结合医院神经内科收治的急性腔隙性卒中患者156例,根据患者的头部MRI检查结果,采用Fazekas评分法将入组患者分为轻度白质病变组(n=76)和中重度白质病变组(n=80)。收集2组患者的一般信息、血管危险因素、实验室指标和其他检查结果,通过24 h ABPM获取血压变异性指标和血压节律,比较和分析影响急性腔隙性卒中患者WMH的相关因素。结果 中重度WMH组的既往卒中史(P=0.005)、急性腔隙性梗死灶数目(P=0.021)、颈动脉斑块等级积分(P=0.041)均高于轻度WMH组;中重度WMH组的全天SBP-SD(P=0.01)、日间SBP-SD(P=0.004)、日间SBP-CV(P=0.018)、日间DBP-SD(P=0.028)均明显升高;在两组血压昼夜节律比较中,中重度WMH组反杓型血压节律的比例显著升高(P=0.03),轻度WMH组杓型血压比例更高(P=0.045)。多因素Logistic回归分析发现,急性腔梗病灶数目(OR=2.114,95%C...     

卒中急性期的血压管理

血压升高是卒中急性期患者的常见并发症对缺血性卒中而言,高血压与脑水肿有关,升高的血压可以避免脑灌注压及脑血流量的降低,而且已有升高血压治疗急性脑缺血的研究报道[1],对于出血性卒中的急性期患者,由于缺乏有力的临床证据,高血压与患者预后的关系目前还不明确.……     

Blood pressure as an independent prognostic factor in acute ischemic stroke

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.     

The time course and determinants of blood pressure within the first 48 h after ischemic stroke

BACKGROUND AND PURPOSE: Previous research suggests that blood pressure falls acutely after ischemic stroke. We aimed to further characterize this fall with a statistical technique that allows the application of regression techniques to serial blood pressure outcome data. METHODS: In a prospectively recruited ischemic stroke cohort, systolic (SBP) and diastolic (DBP) blood pressure was recorded every 4 h until 48 h after stroke. Potential determinants of blood pressure, including stroke severity and acute infection, were also recorded. Mixed effects models were used to model serial blood pressure measurements over time, adjusted for significant determinants. RESULTS: In 156 patients, SBP and DBP fell by 14.9 mm Hg (95% CI 6.2-22.6 mm Hg) and 6.2 mm Hg (95% CI 1.4-10.6 mm Hg), respectively, over the first 48 h after stroke. SBP was higher in patients with premorbid hypertension, a previous history of stroke or TIA, current alcohol use, increasing age, stroke of mild to moderate severity (NIHSS 3-13) and in patients treated with antihypertensives. SBP was lower in smokers. There was a progressive rise in SBP in patients with acute infection. No factors other than time were associated with DBP. CONCLUSIONS: The use of mixed effects models has identified a linear SBP and DBP fall over the first 48 h after stroke. The timing and magnitude of this fall should be accounted for in the design of future prognostic and intervention studies.     

Daily profile of poststroke blood pressure change

Although acute hypertension after stroke is widely recognized, blood pressure changes in relation to the value before stroke onset have been little discussed. We evaluated the daily profile of blood pressure changes from the time before stroke onset through the 14th day after ictus in 38 patients admitted to hospital within 24 hours (7.4 ± 8.8 hours) after a first acute ischemic stroke, whose medical histories, blood pressure measurements, and medications were thoroughly reviewed. The mean arterial blood pressure was 97 ± 13 mm Hg at baseline and 112 ± 17 mm/Hg on admission after ictus. The extent of poststroke blood pressure elevation, (defined as blood pressure on admission after stroke onset less baseline blood pressure at outpatient clinic before stroke onset), and mean daily blood pressure values were calculated through the 14th day after ictus. Three quarter of the subjects had poststroke hypertension, and the extent of poststroke blood pressure elevation correlated significantly with the degree of neurologic recovery (R = 0.43, P < .01). Blood pressure was highest on admission after ictus and fell to the baseline level by day 2 (101 ± 12 mm Hg). Because poststroke blood pressure change resolves spontaneously and is suggestive for neurologic recovery, careful consideration should therefore be given to antihypertensive therapy in patients with acute ischemic stroke.     

联合血压变异性和血清N端脑钠肽前体在急性脑梗死中的临床研究

目的 探讨急性脑梗死患者血压变异性和血清N 端脑钠肽前体(NT-pro-BNP)的水平变化及其两者之间的关系。方法 选取急性脑梗死患者78例作为脑梗死组,抽取56例为对照组,为本院同期非脑血管疾病患者; 对比分析组间血压变异性、血清NT-pro-BNP水平; 对比分析脑梗死组亚组间(脑梗死面积、脑梗死部位、是否合并高血压病、随访90d时的预后)血压变异性、血清NT-pro-BNP水平。结果 脑梗死组血压变异性、血清NT-pro-BNP水平显著高于对照组(P<0.05); 大面积脑梗死组和脑梗死死亡组患者血清NT-pro-BNP水平和24 h收缩压变异系数、24 h舒张压变异系数、白昼收缩压变异系数、白昼舒张压变异系数、夜间收缩压变异系数及夜间舒张压变异系数均分别明显高于非大面积脑梗死组与脑梗死存活组(P<0.01); 脑梗死合并高血压病组血清NT-pro-BNP水平和24 h收缩压变异系数、白昼收缩压变异系数、白昼舒张压变异系数、夜间收缩压变异系数及夜间舒张压变异系数均显著高于脑梗死且血压正常组(P<0.05); 前循环供血区脑梗死组与后循环供血区脑梗死组的24 h收缩压变异系数、24 h舒张压变异系数、白昼收缩压变异系数、白昼舒张压变异系数、夜间收缩压变异系数及夜间舒张压变异系数均有明显差异(P<0.05)。血清NT-pro-BNP水平与血压变异性相关指标24 h收缩压变异系数、24 h舒张压变异系数、白昼收缩压变异系数、白昼舒张压变异系数、夜间收缩压变异系数及夜间舒张压变异系数等呈正相关(r=0.339,0.341,0.339,0.330,0.380,0.374,P<0.01)。结论 急性脑梗死患者血压变异性和血清N 端脑钠肽前体(NT-pro-BNP)的水平明显升高,且血清NT-pro-BNP水平与血压变异性有关。     

The role of blood pressure lowering before and after stroke

PURPOSE OF REVIEW: Elevated blood pressure is one of the most potent risk factors for first ever and recurrent stroke as well as influencing early outcome after acute stroke. There have been a number of significant randomized controlled trials which may influence management in each of these three categories. RECENT FINDINGS: For primary prevention, the recent information from the Heart Outcomes Prevention Evaluation, Losartan Intervention for Endpoint Reduction to Hypertension, Study on Cognition and Prognosis in the Elderly and Australian National Blood Pressure Study support the view that blood pressure lowering protects against stroke regardless of baseline blood pressure level. There is some evidence that blockade of the angiotensin system may give additional protection. For secondary prevention, evidence from the Perindopril Protection against Recurrent Stroke Study shows that blood pressure lowering with perindopril based therapy reduces fatal or non-fatal stroke events, again in hypertensive or normotensive individuals. There is uncertainty about blood pressure lowering in acute stroke, although presentation of the recent Acute Candesartan Cilexetil Evaluation in Stroke Survivors trial in which there was significant protection against vascular events using candesartan suggests that further studies should be undertaken. SUMMARY: Blood pressure lowering for primary prevention of stroke should be undertaken using a variety of therapeutic agents. For secondary stroke prevention perindopril based therapy should be used based on current evidence. Uncertainty still exists as to whether blood pressure lowering in the acute stroke setting is safe or improves outcomes.     

Blood pressure as a prognostic factor after acute stroke

Stroke is the second most common cause of death worldwide and is the complication of hypertension that is most directly linked to blood pressure. Hypertension affects nearly 30% of the world's population; therefore, reducing blood pressure is key for the prevention of stroke. Unlike the established role of hypertension as a risk factor for stroke, the prognostic importance of blood pressure in determining outcome after acute stroke is unclear. The acute hypertensive response occurs in more than 50% of all patients with acute stroke and is associated with poor prognosis. The relation between the outcome of acute stroke and blood pressure is U-shaped, with the best outcome at systolic blood-pressure levels ranging from about 140 to 180 mm Hg. The evidence that decreasing blood pressure in hypertensive patients with acute ischaemic or haemorrhagic stroke improves prognosis needs further confirmation. Whether raising blood pressure to improve perfusion of ischaemic brain areas is beneficial remains even more uncertain. Present guidelines for the management of blood pressure in patients with acute stroke are not evidence-based, but results from ongoing trials might provide more informed recommendations for the future.     

伴有高血压的颅内动脉粥样硬化性狭窄及相关性缺血性脑卒中的降血压治疗

伴有高血压的颅内动脉粥样硬化性狭窄(ICAS)是降压治疗的适应证。制定目标血压值,除了要考虑ICAS患者的血压水平外,还要考虑其基础疾病以及年龄。目前没有统一的目标血压值。对ICAS相关性急性缺血性脑卒中(AIS)的高血压是否要降压,以及降压的最佳血压值,尚无统一意见。对过高的血压进行降压,以及避免过度降血压,是业内学者的共识。要根据患者的基础疾病决定降低血压幅度,对伴有高血压的ICAS相关性缺血性脑卒中患者,降压治疗能防止其复发。目前,还没有关于ICAS及其相关性缺血性脑卒中的血压管理标准。     

Prognostic factors in the acute phase of haemorrhagic stroke

The aim of the study was establishing which parameters play a significant prognostic role in acute haemorrhagic stroke in its acute phases (during 30 days from stroke onset). The material included 110 patients with haemorrhagic stroke (HS) treated in the years 1997-1999 at the II Neurology Department, Institute of Psychiatry and Neurology in Warsaw or at the Neurology Department, Hospital in Pi?a. The analysis of risk factors, fitness before stroke and on the first day of the disease was based on history data. On the first day of the disease the assessment included state of consciousness, brain stem signs, vomiting, stroke type on the basis of clinical condition (according to Oxford classification, OCSP), blood pressure, body temperature measurements, intensity of neurological signs according to Scandinavian scale (SSS). In the blood glucose level, fibrinogen, leucocyte count and ESR were determined. In the first week consciousness state, blood pressure and miction were checked repeatedly. It was found that serious consciousness disturbances, stroke type TACS, POCS and severe not classified stroke, presence of brain stem involvement, low SSS score, high body temperature, high leucocyte count and glucose level were more frequent in patients who died within 30 days after stroke onset. Prognostically important were also instability of blood pressure and urinary incontinence in the first week. All clinical observation and laboratory analyses of prognostic importance in the acute phase of HS can be done in typical hospital settings.     

脑卒中急性期血压变化规律及影响因素的研究

目的 观察脑卒中急性期血压变化规律及其影响因素.方法 研究发病24h内入院的急性脑卒中患者704例.监测入院后7d内血压,收集详细病史资料,对病程中伴发疾病进行评分,记录入院后血压的管理方式及干预时间等.运用简单和多因素统计方法进行数据的统计分析.结果 脑卒中急性期血压升高,并且存在自发下降趋势,8h内下降最明显,36h趋于稳定.其中脑梗死患者血压在入院30h内趋于稳定,脑出血患者血压在入院96h内趋于稳定.出血性卒中患者血压要高于缺血性卒中患者.缺血性卒中患者TOAST分型和OCSP分型间血压无显著差异.神经功能缺损程度影响入院时和入院后36h内血压.独立影响入院时收缩压的因素有卒中类型、入院时NIHSS评分、心脏病史、高血压史,其中心脏病史与入院时血压成负相关.独立影响入院时舒张压的因素有卒中类型、年龄、入院NIHSS评分、高血压史.年龄与入院时舒张压呈负相关.独立影响7d内平均收缩压的因素有卒中类型、入院NIHSS评分、伴发疾病评分、心脏病史、高血压史、既往史评分.心脏病史与7d平均血压呈负相关.影响入院7d内舒张压的因素有卒中类型、年龄、伴发疾病评分、入院NIHSS评分、心脏病史.心脏病史和年龄与7d平均舒张压呈负相关.结论 脑卒中急性期血压升高,并有自发性下降趋势.卒中类型及高血压史与血压呈正相关,心脏病史及年龄与血压呈负相关.