Early antihypertensive treatment and clinical outcomes in acute ischemic stroke: subgroup analysis by baseline blood pressure.
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ABSTRACT:
SUBMITTER: He WJ
PROVIDER: S-EPMC6368851 | biostudies-literature | 2018 Jun
REPOSITORIES: biostudies-literature
Publications
Early antihypertensive treatment and clinical outcomes in acute ischemic stroke: subgroup analysis by baseline blood pressure.
He William J WJ Zhong Chongke C Xu Tan T Wang Dali D Sun Yingxian Y Bu Xiaoqing X Chen Chung-Shiuan CS Wang Jinchao J Ju Zhong Z Li Qunwei Q Zhang Jintao J Geng Deqin D Zhang Jianhui J Li Dong D Li Yongqiu Y Yuan Xiaodong X Zhang Yonghong Y Kelly Tanika N TN
Journal of hypertension 20180601 6
<h4>Background</h4>We studied the effect of early antihypertensive treatment on death, major disability, and vascular events among patients with acute ischemic stroke according to their baseline SBP.<h4>Methods</h4>We randomly assigned 4071 acute ischemic stroke patients with SBP between 140 and less than 220 mmHg to receive antihypertensive treatment or to discontinue all antihypertensive medications during hospitalization. A composite primary outcome of death and major disability and secondary ...[more]
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Project description:The optimal time to initiate antihypertensive therapy among patients with acute ischemic stroke remains uncertain. We tested the effects of blood pressure reduction among patients with acute ischemic stroke according to time from onset to initiation of antihypertensive treatment.We randomly assigned 4071 acute ischemic stroke patients with elevated SBP to receive antihypertensive treatment or to discontinue all antihypertensive medications during hospitalization. The primary outcome was a combination of death and major disability, and secondary outcomes included the modified Rankin score, recurrent stroke, vascular disease events, and all-cause mortality.At 24?h after randomization, the differences in SBP reductions were 8.7, 9.5, and 9.6?mmHg between the antihypertensive treatment and control groups among patients receiving treatment within less than 12, 12-23, and 24-48?h after stroke onset, respectively (P?<?0.001 in all subgroups). At day 14 or hospital discharge, the primary and secondary outcomes were not significantly different between the treatment and control groups in all subgroups. At the 3-month follow-up, death or major disability [odds ratio (OR) 0.73; 95% confidence interval (CI) 0.55-0.96; P?=?0.03], recurrent stroke (OR 0.25; 95% CI 0.08-0.74; P?=?0.01), and vascular events (OR 0.41; 95% CI 0.18-0.95; P?=?0.04) were significantly reduced in the antihypertensive treatment group only among participants who received treatment between 24 and 48?h.Blood pressure reduction might reduce 3-month death and major disability and recurrent stroke among patients with acute ischemic stroke who receive antihypertensive treatment between 24 and 48?h after stroke onset.ClinicalTrials.gov Identifier: NCT01840072.
| S-EPMC5785332 | biostudies-literature
Project description:BackgroundClinical trials have generally showed a neutral effect of blood pressure (BP) reduction on clinical outcomes among acute ischemic stroke patients. We conducted a prespecified subgroup analysis to assess whether disease severity modifies the effect of early antihypertensive treatment on death and disability among patients with acute ischemic stroke.MethodsIn the China Antihypertensive Trial in Acute Ischemic Stroke, 4,071 patients with acute ischemic stroke and elevated BP were randomly assigned to receive antihypertensive treatment or to discontinue all hypertension medications within 48 h of symptom onset. The primary outcome was a combination of death and major disability at 14 days or hospital discharge. In this subgroup analysis, participants were categorized into 3 groups according to their baseline NIH Stroke Scale (NIHSS) scores (0-4, 5-15, or ≥16).ResultsAt 24 h after randomization, mean systolic BP differences (95% CIs) were -8.5 (-10.0 to -7.1), -9.8 (-11.4 to -8.3), and -9.1 (-14.4 to -3.8) mm Hg between the treatment and control groups (all p values <0.001) for patients with a baseline NIHSS score of 0-4, 5-15, and ≥16, respectively. At day 7 after randomization, the corresponding mean systolic BP differences were -9.3 (-10.5 to -8.2), -9.1 (-10.3 to -7.8), and -10.1 (-15.1 to -5.1) mm Hg between the treatment and control groups (all p values <0.001). The primary outcome was not significantly different between the treatment and control groups at day 14 or hospital discharge among all NIHSS subgroups (p value for homogeneity = 0.66). ORs (95% CI) associated with treatment were 1.14 (0.87-1.49, p = 0.33), 1.04 (0.86-1.25, p = 0.70), and 0.67 (0.18-2.44, p = 0.54) for patients with a baseline NIHSS score of 0-4, 5-15, and ≥16, respectively. The composite outcome of death and major disability at 3-month follow-up did not differ between the 2 comparison groups for all NIHSS subgroups. In addition, vascular events and recurrent stroke were not significantly different between the 2 comparison groups at the 3-month follow-up visit among all NIHSS subgroups except that there was a suggestive risk reduction for recurrent stroke among those with an NIHSS score of 5-15 (OR 0.45, 95% CI 0.20-0.99, p = 0.05).ConclusionEarly BP reduction with antihypertensive medications did not reduce or increase the risk of death, major disabilities, recurrent instances of stroke, and vascular events in acute ischemic stroke patients with a variety of disease severities.
| S-EPMC8784237 | biostudies-literature
Project description:High blood pressure (BP) is frequent in acute ischemic stroke (IS). However, the impact of BP change patterns during acute phase on clinical outcomes is not conclusive. This study aims to investigate the association between the acute-phase BP trajectories and clinical outcomes in IS patients with high admission BP. The cohort consisted of 316 IS patients with admission systolic BP (SBP) ≥160 mm Hg. SBP trajectories during the first 7 days after onset were characterized using a random effects model. The patients were classified into three groups based on the SBP trajectory curve parameters: sustained high SBP (T1), moderate decrease (T2), and rapid decrease in SBP (T3). Poor outcomes were defined as modified Rankin scale score ≥3 in 3 months after onset. The relationship between SBP trajectory groups and the outcome was examined in multivariable logistic regression models. The decreasing trend was greater in the favorable than in the poor outcome group (P = 0.028 for difference in linear slopes). The incidence of poor outcomes was 25.9%, 13.5%, and 9.8% in T1 (n = 54), T2 (n = 170), and T3 (n = 92) groups, respectively. Compared with T1 group, the decrease in SBP in T2 and T3 groups was significantly associated with lower risk of the poor outcome (odds ratio = 0.25, 95% confidence interval = 0.10-0.67, P = 0.006). These findings suggest that a decrease in BP in the acute phase is predictive of favorable outcomes in IS patients. BP trajectories have a greater power to detect the association than individual BP values at one time-point.
| S-EPMC8030386 | biostudies-literature
Project description:Background Although the effect of blood pressure on poststroke outcome is well recognized, the long-term trajectory of blood pressure after acute ischemic stroke and its influence on outcomes have not been studied well. Methods and Results We analyzed systolic blood pressure (SBP) measurements in 5514 patients with acute ischemic stroke at ≥2 of 7 prespecified time points during the first year after stroke among those enrolled in a multicenter prospective registry. Longitudinal SBPs were categorized using a group-based trajectory model. The primary outcome was a composite of stroke recurrence, myocardial infarction, and all-cause mortality up to 1 year after stroke. The study subjects were categorized into 4 SBP trajectory groups: low (27.0%), moderate (59.5%), persistently high (1.2%), and slowly dropping (12.4%). In the first 3 groups, SBP decreased during the first 3 to 7 days and remained steady thereafter. In the slowly dropping SBP group, SBPs decreased from 182 to 135 mm Hg during the first 30 days, then paralleled the trajectory of the moderate SBP group. Compared with the reference, the moderate SBP group, the slowly dropping SBP group was at higher risk for the primary outcome (adjusted hazard ratio [HR], 1.32; 95% CI, 1.05‒1.65) and mortality (adjusted HR, 1.35; 95% CI, 1.03‒1.78). Primary outcome rates were similarly high in the persistently high SBP group. Conclusions Four 1-year longitudinal SBP trajectories were identified in patients with acute ischemic stroke. Patients in the slowly dropping SBP and persistently high SBP trajectory groups were prone to adverse cardiovascular outcomes after stroke.
| S-EPMC9075074 | biostudies-literature
Project description:BACKGROUND:High blood pressure (BP) is associated with worse clinical outcomes in the setting of acute ischemic stroke, but the optimal blood pressure target is still a matter of debate. We aimed to study the association between baseline BP and mortality in acute ischemic stroke patients treated by mechanical thrombectomy. METHODS AND RESULTS:A total of 1332 acute ischemic stroke patients treated by mechanical thrombectomy were enrolled (from January 2012 to June 2016) in the ETIS (Endovascular Treatment in Ischemic Stroke) registry. Linear and polynomial logistic regression models were used to assess the association between BP and mortality and functional outcome at 90 days. Highest mortality was found at lower and higher baseline systolic blood pressure (SBP) values following a J- or U-shaped relationship, with a nadir at 157 mm Hg (95% confidence interval 143-170). When SBP values were categorized in 10-mm Hg increments, the odds ratio for all-cause mortality was 3.78 (95% confidence interval 1.50-9.55) for SBP<110 mm Hg and 1.81 (95% confidence interval 1.01-3.36) for SBP≥180 mm Hg using SBP≥150 to 160 mm Hg as reference. The rate of favorable outcome was the highest at low SBP values and lowest at high SBP values, with a nonlinear relationship; in unplanned exploratory analysis, an optimal threshold SBP≥177 mm Hg was found to predict unfavorable outcome (adjusted odds ratio 0.47; 95% confidence interval 0.31-0.70). CONCLUSION:In acute ischemic stroke patients treated by mechanical thrombectomy, baseline SBP is associated with all-cause mortality and favorable outcome. In contrast to mortality, favorable outcome rate was the highest at low SBP values and lowest at high SBP values. Further studies are warranted to confirm these findings.
| S-EPMC5721857 | biostudies-other
Project description:Increased blood pressure (BP) management following acute ischemic stroke (AIS) remains controversial. This study aimed to identify the association between BP and clinical outcomes in AIS patients administered lytic medication in the TIMS-China (thrombolysis implementation and monitor of acute ischemic stroke in China) database.The sample comprised 1128 patients hospitalized within 4.5 hours (h) of AIS for intravenous recombinant tissue plasminogen activator (i.v. rt-PA) thrombolysis. Systolic BP (SBP) and diastolic BP (DBP) at baseline, 2 h and 24 h after treatment, and changes from baseline were analyzed. The study outcomes comprised a favorable outcome (modified Rankin Scale 0-1 at 90 days) and symptomatic intracerebral hemorrhage (SICH), analyzed using logistic regression, with low BP as the reference group.Lower BP (baseline, 2 h, and 24 h) was beneficial in AIS patients and significantly related to a favorable outcome (P<0.05). A substantial BP decrease at 24 h after rt-PA thrombolysis was significantly associated with a favorable outcome compared with a moderate BP decrease (P = 0.0298). A SBP >160 mmHg 2 h after rt-PA thrombolysis was significantly associated with SICH compared with a SBP <140 mmHg (P = 0.0238). An increase or no change (>25 mmHg) in SBP was significantly associated with SICH (P = 0.002) compared with a small SBP decrease (1-9 mmHg).This study provides novel evidence that lower BP within the first 24 h is associated with a more favorable outcome and less frequent SICH in AIS patients administered lytic medication. Routine BP-lowering treatment should be considered in AIS patients following lytic medication.
| S-EPMC4735460 | biostudies-other
Project description:High blood pressure is common in acute stroke patients. Very high as well as very low blood pressure is associated with poor outcome. Spontaneous fall of blood pressure within the first few days after stroke was associated both with neurological improvement and impairment. Several randomized trials investigated the pharmacological reduction of blood pressure versus control. Most trials showed no significant difference in their primary outcome apart from the INWEST trial which found an increase of poor outcome when giving intravenous nimodipine. Nevertheless, useful information can be extracted from the published data to help guide the clinician's decision. Blood pressure should only be lowered when it is clearly elevated, and early after onset, reduction should be moderate but may be achieved rapidly. No clear recommendations can be given on the substances to use; however, care should be taken with intravenous calcium channel blockers and angiotensin receptor antagonists. Two ongoing randomized trials will help to solve the questions on blood pressure management in acute stroke.
| S-EPMC3655558 | biostudies-other
Project description:We investigated the relationship between the mean blood pressure (BP) at 24-72 h and the clinical outcomes after acute ischemic stroke (AIS) in patients treated with reperfusion therapy. The primary outcome was measured using the modified Rankin Scale (mRS) at 3 months after AIS, and was based on the mean systolic BP at 24-72 h post-AIS. Favorable outcome was defined as mRS scores of 0-2. A total of 1,540 patients treated with reperfusion therapy were enrolled in the study. Favorable outcomes occurred more frequently in patients with BP ≤ 130/80 mmHg, and the risks of symptomatic intracranial hemorrhage and early neurological deterioration were lower in this optimal BP group. Multivariable analysis showed a significant association between mean BP ≤ 130/80 mmHg at 24-72 h and favorable outcomes at 3 months after AIS (odds ratio 2.95, 95% confidence interval 2.32-3.77, p < 0.001). Prespecified subgroup analyses showed that BP ≤ 130/80 mmHg had a more significant impact on clinical outcome in patients with recanalization than in those without recanalization. These data indicate that a mean BP of ≤ 130/80 mmHg at 24-72 h post-AIS is independently associated with favorable outcomes in patients treated with reperfusion therapy, particularly in those with recanalization.
| S-EPMC6450931 | biostudies-literature
Project description:Limited data exist evaluating the effect of blood pressure (BP) on clinical outcomes among patients with acute ischemic stroke with large vessel occlusion treated with mechanical thrombectomy (MT). We sought to evaluate the association of BP levels on clinical outcomes among patients with acute ischemic stroke with large vessel occlusion treated with MT. Studies were identified that reported the association of systolic BP (SBP) or diastolic BP levels before, during, or after MT on the outcomes of patients with acute ischemic stroke treated with MT. Unadjusted and adjusted analyses of studies reporting odds ratios (ORadj) per 10 mm?Hg BP increment were performed. Our analysis included 25 studies comprising 6474 patients. Higher pre-MT mean SBP (P=0.008) and post-MT maximum SBP (P=0.009) levels were observed in patients who died within 3 months. Patients with 3-month functional independence were noted to have lower pre-MT (P<0.001) and post-MT maximum SBP levels (P<0.001). In adjusted analyses, increasing post-MT maximum SBP and diastolic BP levels were associated with 3-month mortality (ORadj, 1.19 [95% CI,1.00-1.43]; I2=78%, P value for Cochran Q test: 0.001) and symptomatic intracranial hemorrhage (ORadj, 1.65 [95% CI, 1.11-2.44]; I2=0%, P value for Cochran Q test: 0.80), respectively. Increasing pre- and post-MT mean SBP levels were associated with lower odds of 3-month functional independence (ORadj, 0.86 [95% CI, 0.77-0.96]; I2=18%, P value for Cochran Q test: 0.30) and (ORadj, 0.80 [95% CI, 0.72-0.89]; I2=0%, P value for Cochran Q test: 0.51), respectively. In conclusion, elevated BP levels before and after MT are associated with adverse outcomes among patients with acute ischemic stroke with large vessel occlusion.
| S-EPMC7233454 | biostudies-literature
Project description:Background: Intravenous thrombolysis (IVT) therapy is currently one of the best medical treatments available for patients with acute ischemic stroke. Studies have shown that blood pressure (BP) changes in patients treated with IVT are significantly correlated with prognosis. Objective: Our study aimed to determine the relationship between BP changes during recombinant tissue plasminogen activator (rt-PA) infusion and the 3-month prognosis evaluated using the modified Rankin Scale (mRS) and determine the factors influencing BP changes during rt-PA infusion. Methods: Consecutive patients who were treated with IVT and admitted to our stroke center between May 2015 and October 2017 were analyzed retrospectively. Patients were divided into two groups according to their 3-month prognosis status: patients with mRS ≤ 2 were defined as "favorable outcome group" and those with mRS ≥ 3 as "unfavorable outcome group". First, the factors affecting prognosis after thrombolysis were analyzed. Second, we analyzed the relationship between BP and the prognosis. BP was taken before and at regular intervals of 15 min during the rt-PA infusion (1 h). The average value of BP during thrombolysis was calculated and compared to the baseline BP. BP decrease was defined as the difference between the baseline BP and the average BP, provided it was greater than 0 mmHg. Third, univariate and multivariate analyses were performed to identify factors that may contribute to BP decrease. Results: In total, 458 patients were included. Patients with a lower baseline National Institute of Health Stroke Scale (NIHSS) score (8.25 ± 5.57 vs. 13.51 ± 7.42, P < 0.001), a higher Alberta Stroke Program Early CT Score (ASPECTS; 8.65 ± 1.82 vs. 8.13 ± 2.00, P = 0.005), decreased BP during thrombolysis (69.4% vs. 59.8%, P = 0.037), and steady BP (SD < 10 mmHg) were more likely to have a favorable outcome (73.9% vs. 60.6%, P = 0.019). High baseline BP (OR > 1), hypertension history (OR < 1), and baseline ASPECTS (OR > 1) were independent factors of BP change during thrombolysis. Conclusion: Patients with decreased or steady BP during thrombolysis were more likely to have a favorable outcome. Baseline ASPECTS, baseline NIHSS score, and hypertension history influenced BP changes during thrombolysis.
| S-EPMC7746539 | biostudies-literature