Blood Pressure Variability and Cardiovascular Outcomes in Patients With Prior Stroke

Abstract

Background and Purpose— Every year in the United States, almost 185 000 ischemic strokes occur in patients with a prior stroke. Recurrent stroke has significantly higher morbidity and mortality. Among modifiable risk factors for recurrent stroke, hypertension is the most prevalent. Reducing systolic blood pressure is standard of care for secondary stroke prevention. Recent literature suggests that increased blood pressure variability (BPV) is associated with primary stroke, although studies have not convincingly shown that it is associated with recurrent stroke, which was the goal of this analysis. Methods— We conducted a secondary analysis of 17 916 patients in the PRoFESS (Prevention Regimen for Effectively Avoiding Second Strokes) trial, which is the largest trial of patients with potential recurrent stroke. We calculated BPV and evaluated its effect on recurrent stroke (composite and stratified by ischemic or hemorrhagic stroke), major cardiovascular events (death from cardiovascular causes, recurrent stroke, myocardial infarction, or new or worsening heart failure), and all-cause death. Results— Both systolic and diastolic BPV were associated with recurrent stroke, major cardiovascular events, and all-cause death. The association with stroke was significant for ischemic, but not hemorrhagic, stroke. For every 10-point increase in BPV (systolic SD, range =0–54.2), the hazard ratio for a recurrent ischemic stroke was 1.15 (95% CI, 1.02–1.32; P =0.02), for major cardiovascular events was 1.19 (95% CI, 1.09–1.31; P <0.001), and for all-cause death was 1.24 (95% CI, 1.10–1.39; P <0.001). Conclusions— Our study adds to the growing body of literature suggesting that BPV is an important and potentially modifiable risk factor for ischemic stroke, cardiovascular events, and all-cause death. Specifically, it is the first study to demonstrate that increased BPV is associated with recurrent ischemic stroke and that diastolic BPV can be as important as systolic BPV. Future work should focus on evaluating whether actively reducing BPV, using widely available and inexpensive antihypertensive medications, reduces the risk of cardiovascular disease.

A Meta-Analysis of Prognostic Factors in Patients with Posterior Circulation Stroke after Mechanical Thrombectomy

“…We observe that diabetes correlates with poorer outcomes in posterior circulation stroke patients after MT. They face long-term adverse effects, including BP variability [96], new-onset atrial fibrillation [53], poststroke depression [97], and poststroke cognitive impairment [98, 99], which are associated with recurrent stroke and higher mortality. Secondary onset after a stroke is estimated at 9%, which is significantly higher than in the general population [100, 101].…”

How We Manage Hypertension in a Patient with a Recent Stroke

“…Current guidelines recommend use of out-of-office BP measured using an ambulatory BP monitor or home BP monitor for the diagnosis of hypertension. We also use out-of-office BP measurements in patients with an established diagnosis of hypertension to complement office BP measurements and provide a more comprehensive overview of the BP profile, particularly in patients who may be prone to BP lability, such as after a stroke (7). Moreover, home BP monitoring is associated with improved BP control rates and can be used to identify white coat and masked hypertension, which may have treatment implications.…”

Visit-to-Visit Blood PressureVariations and Hemodynamic Deterioration in Atherosclerotic Major Cerebral ArteryDisease

“…Recent studies have shown that increased visit-to-visit variability in office BP is a powerful risk factor for stroke, which is independent of the BP level, despite the potential impact of hospital stress. 11,12 The mechanism by which visit-to-visit BP variability causes stroke remains unclear; however, several studies have shown that high visit-to-visit BP variability, as well as 24h ambulatory BP variability, is associated with arterial stiffness, endothelial dysfunction, and atherosclerosis, suggesting that alterations in vascular function may occur with high BP variability. 13À16 Hence, increased visit-to-visit BP variability could impair the function of cerebral collaterals in patients with atherosclerotic major cerebral artery disease, leading to hemodynamic impairment.…”