Blood Pressure Variability After Cerebrovascular Events: A Possible New Therapeutic Target

Hawkes, Maximiliano A.; Anderson, Craig S.; Rabinstein, Alejandro A.

doi:10.1212/wnl.0000000000200856

Cited by 14 publications

(8 citation statements)

References 46 publications

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“…Some studies suggest more stable nimodipine concentrations with IV formulation [ 27 ] or a lower bioavailability of enteral nimodipine [ 28 ] which was not supported by others [ 29 ]. It is reasonable that continuous IV nimodipine application could smooth blood pressure control and avoid blood pressure fluctuations, which are known to be associated with DCI and poor functional outcome in patients with SAH [ 30 , 31 ].…”

Section: Discussionmentioning

confidence: 99%

Blood Pressure Changes in Association with Nimodipine Therapy in Patients with Spontaneous Subarachnoid Hemorrhage

et al. 2023

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Background Nimodipine is recommended to prevent delayed cerebral ischemia in patients with spontaneous subarachnoid hemorrhage (SAH). Here, we studied hemodynamic side effects of different nimodipine formulations (per os [PO] and intravenous [IV]) in patients with SAH undergoing continuous blood pressure monitoring. Methods This observational cohort study includes consecutive patients with SAH (271 included in the IV group, 49 in the PO group) admitted to a tertiary care center between 2010 and 2021. All patients received prophylactic IV or PO nimodipine. Hemodynamic responses were evaluated based on median values within the first hour after continuous IV nimodipine initiation or PO nimodipine application (601 intakes within 15 days). Significant changes were defined as > 10% drop in systolic blood pressure (SBP) or diastolic blood pressure from baseline (median values 30 min before nimodipine application). With the use of multivariable logistic regression, risk factors associated with SBP drops were identified. Results Patients were admitted with a median Hunt & Hess score of 3 (2–5; IV 3 [2–5], PO 1 [1–2], p < 0.001) and were 58 (49–69) years of age. Initiation of IV nimodipine was associated with a > 10% SBP drop in 30% (81/271) of patients, with a maximum effect after 15 min. A start or increase in noradrenaline was necessary in 136/271 (50%) patients, and colloids were administered in 25/271 (9%) patients within 1 h after IV nimodipine initiation. SBP drops > 10% occurred after 53/601 (9%) PO nimodipine intakes, with a maximum effect after 30–45 min in 28/49 (57%) patients. Noradrenaline application was uncommon (3% before and 4% after nimodipine PO intake). Hypotensive episodes to an SBP < 90 mm Hg were not observed after IV or PO nimodipine application. In multivariable analysis, only a higher SBP at baseline was associated with a > 10% drop in SBP after IV (p < 0.001) or PO (p = 0.001) nimodipine application, after adjusting for the Hunt & Hess score on admission, age, sex, mechanical ventilation, days after intensive care unit admission, and delayed cerebral ischemia. Conclusions Significant drops in SBP occur in one third of patients after the start of IV nimodipine and after every tenth PO intake. Early recognition and counteracting with vasopressors or fluids seems necessary to prevent hypotensive episodes.

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Section: Discussionmentioning

confidence: 99%

Blood Pressure Changes in Association with Nimodipine Therapy in Patients with Spontaneous Subarachnoid Hemorrhage

et al. 2023

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“…Post-stroke BP fluctuations represent a multifactorial and intricate physiological process ( 6 ). Numerous studies have revealed the correlation between preoperative, intraoperative, and postoperative BP levels and clinical outcomes as an crucial clinical factor ( 7 , 8 ).…”

Section: Introductionmentioning

confidence: 99%

Machine learning models reveal the critical role of nighttime systolic blood pressure in predicting functional outcome for acute ischemic stroke after endovascular thrombectomy

Xu,

Qi,

Liu

et al. 2024

Front. Neurol.

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BackgroundBlood pressure (BP) is a key factor for the clinical outcomes of acute ischemic stroke (AIS) receiving endovascular thrombectomy (EVT). However, the effect of the circadian pattern of BP on functional outcome is unclear.MethodsThis multicenter, retrospective, observational study was conducted from 2016 to 2023 at three hospitals in China (ChiCTR2300077202). A total of 407 patients who underwent endovascular thrombectomy (EVT) and continuous 24-h BP monitoring were included. Two hundred forty-one cases from Beijing Hospital were allocated to the development group, while 166 cases from Peking University Shenzhen Hospital and Hainan General Hospital were used for external validation. Postoperative systolic BP (SBP) included daytime SBP, nighttime SBP, and 24-h average SBP. Least absolute shrinkage and selection operator (LASSO), support vector machine-recursive feature elimination (SVM-RFE), Boruta were used to screen for potential features associated with functional dependence defined as 3-month modified Rankin scale (mRS) score ≥ 3. Nine algorithms were applied for model construction and evaluated using area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and accuracy.ResultsThree hundred twenty-eight of 407 (80.6%) patients achieved successful recanalization and 182 patients (44.7%) were functional independent. NIHSS at onset, modified cerebral infarction thrombolysis grade, atrial fibrillation, coronary atherosclerotic heart disease, hypertension were identified as prognostic factors by the intersection of three algorithms to construct the baseline model. Compared to daytime SBP and 24-h SBP models, the AUC of baseline + nighttime SBP showed the highest AUC in all algorithms. The XGboost model performed the best among all the algorithms. ROC results showed an AUC of 0.841 in the development set and an AUC of 0.752 in the validation set for the baseline plus nighttime SBP model, with a brier score of 0.198.ConclusionThis study firstly explored the association between circadian BP patterns with functional outcome for AIS. Nighttime SBP may provide more clinical information regarding the prognosis of patients with AIS after EVT.

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“…Higher blood pressure variability (BPV) in the setting of both acute ischemic stroke (AIS) and hemorrhagic stroke has been associated with a higher risk of death and recurrent stroke, as well as worse poststroke functional outcomes. [1][2][3][4][5][6][7] However, the relationship between BPV and prognosis is not unique to patients with stroke and has been observed in a variety of acute illnesses. [8][9][10] Among nonstroke intensive care unit (ICU) patients, high BPV has been identified as a risk factor for increased mortality during the ICU stay and after discharge.…”

Section: Introductionmentioning

confidence: 99%

Association of Blood Pressure Variability With Death and Discharge Destination Among Critically Ill Patients With and Without Stroke

et al. 2023

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Background/Objective It is unclear if blood pressure variability’s (BPV) association with worse outcomes is unique to stroke patients or a risk factor among all critically-ill patients. We (1) determined if BPV differed between stroke and non-stroke patients, (2) examined BPV’s associations with in-hospital death and favorable discharge destination in stroke and non-stroke patients, and (3) assessed how minimum mean arterial pressure (MAP) – a correlate of illness severity and cerebral perfusion – impacts these associations.Methods:This is a retrospective analysis of adult ICU patients hospitalized between 2001 and 2012 from the Medical Information Mart for Intensive Care III (MIMIC-III) database. Confounder-adjusted logistic regressions determined associations between BPV, measured as standard deviation (SD) and Average real variability (ARV), and a) in-hospital death and b) favorable discharge, with testing of minimum MAP for effect modification.Results:BPV was higher in stroke patients (N=2,248) compared to non-stroke patients (N=9,085) (SD Mean difference: 2.3, 95% CI: 2.1-2.6, p<0.01). After adjusting for minimum tertile of MAP and other confounders, higher SD remained significantly associated (P <0.05) with higher odds of in-hospital death for patients with acute ischemic strokes (AIS, OR 2.7, 95% CI: 1.5-4.8), intracerebral hemorrhage (ICH, OR 2.6, 95% CI: 1.6-4.3), subarachnoid hemorrhage (SAH, OR 3.4, 95% CI: 1.2-9.3), and pneumonia (OR 1.9, 95% CI: 1.1-3.3); and lower odds of favorable discharge destination in patients with ischemic stroke (OR 0.3, 95% CI: 0.2-0.6) and intracerebral hemorrhage (OR 0.4, 95% CI: 0.3-0.6). No interaction was found between minimum MAP tertile with SD (P>0.05). Higher ARV was not significantly associated with increased risk of death in any condition when adjusting for illness severity, but portended worse discharge destination in those with AIS (ORfavorable discharge0.4, 95% CI: 0.3-0.7), ICH (ORfavorable discharge0.5, 95% CI: 0.3-0.7), sepsis (ORfavorable discharge0.8, 95% CI: 0.6-1.0), and pneumonia (ORfavorable discharge0.5, 95% CI: 0.4-0.8).Discussion:BPV is higher and generally associated with worse outcomes among stroke compared to non-stroke patients. BPV in AIS and ICH patients may be a marker of central autonomic network injury, though clinician-driven blood pressure goals likely contribute to the association between BPV and outcomes.

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Blood Pressure Variability After Cerebrovascular Events: A Possible New Therapeutic Target

Cited by 14 publications

References 46 publications

Blood Pressure Changes in Association with Nimodipine Therapy in Patients with Spontaneous Subarachnoid Hemorrhage

Blood Pressure Changes in Association with Nimodipine Therapy in Patients with Spontaneous Subarachnoid Hemorrhage

Machine learning models reveal the critical role of nighttime systolic blood pressure in predicting functional outcome for acute ischemic stroke after endovascular thrombectomy

Association of Blood Pressure Variability With Death and Discharge Destination Among Critically Ill Patients With and Without Stroke

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