Blood Pressure and Outcomes After Ischemic Stroke

Study Questions:

What is the association of blood pressure (BP) and in-hospital outcomes in patients with acute ischemic stroke?

Methods:

Patients in the Get With The Guidelines-Stroke registry with acute ischaemic stroke were included. Admission systolic and diastolic BP was used to compute mean arterial pressure (MAP) and pulse pressure. The outcomes of interest were: in-hospital mortality, not discharged home, inability to ambulate independently at discharge, and hemorrhagic complications due to thrombolytic therapy. To display the relationship between BP and outcomes, the investigators graphed the adjusted odds ratio (OR) compared with the reference values, along with observed event rates for groups defined by 10 mm Hg increments.

Results:

A total of 309,611 patients with an ischemic stroke were included. There was a J-shaped/U-shaped relationship between systolic BP and outcomes. Both lower and higher systolic BP values, compared with a central reference value, had higher risk of in-hospital death [e.g., adjusted OR (95% confidence interval) (OR[CI] = 1.16[1.13–1.20] for 120 vs. 150 mm Hg and 1.24[1.19–1.30] for 200 vs. 150 mm Hg], not discharged home (OR[CI] = 1.11[1.09–1.13] for 120 vs. 150 mm Hg and 1.15[1.12–1.18] for 200 vs. 150 mm Hg), and inability to ambulate independently at discharge (OR[CI] = 1.16[1.13–1.18] for 120 vs. 150 mm Hg and 1.09[1.06–1.11] for 200 vs. 150 mm Hg). However, risk of hemorrhagic complications of thrombolytic therapy was lower with lower systolic BP (OR [CI] = 0.89[0.83–0.97] for 120 vs. 150 mm Hg), while higher with higher systolic BP (OR [CI] = 1.21[1.11–1.32] for 200 vs. 150 mm Hg). The results were largely similar for admission diastolic BP, MAP, and pulse pressure.

Conclusions:

The authors concluded that in patients hospitalized with ischemic stroke, J-shaped or U-shaped relationships were observed between BP variables and short-term outcomes.

Perspective:

This analysis of over 300,000 patients with ischemic stroke showed a J-shaped/U-shaped relationship between BP variables and in-hospital outcomes, including death, with higher adverse events in the groups with higher and lower BP above the reference range. Among patients who underwent thrombolytic therapy, those with lower systolic BP had lower odds of in-hospital outcomes, suggesting that they tolerated lower systolic BP better than those who did not undergo thrombolytic therapy. In addition, all four BP variables (systolic, diastolic, MAP, or pulse pressure) were predictors of in-hospital death, with the strongest predictor being MAP. These data highlight the need for careful and meticulous monitoring of BP after an ischemic stroke.

Clinical Topics: Heart Failure and Cardiomyopathies, Prevention, Hypertension

Keywords: Arterial Pressure, Blood Pressure, Blood Pressure Determination, Hemorrhage, Hospital Mortality, Hypertension, Outcome Assessment (Health Care), Primary Prevention, Registries, Stroke, Systole, Thrombolytic Therapy, Vascular Diseases


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