Association Between Elevated Blood Pressure at Admission and Clinical Outcome in Patients with Acute Anterior Circulation Ischemic Stroke in Indonesia V. Puspitasari1, A.D. Vatvani2, K. Waren2, L.M. Rouly2
1Department of Neurology, Faculty of Medicine, Universitas
Pelita Harapan, Tangerang, Banten, Indonesia 2Faculty of Medicine, Universitas Pelita Harapan, Tangerang, Banten, Indonesia Table 2. Association between Elevated BP and Clinical Outcome
Background Short-term elevation of blood pressure(BP) is frequent in patients presenting with acute ischemic stroke. Its effect on clinical outcome is still not clear and the results are still contradicting.
Objectives To find the association between elevated BP at admission and clinical outcome in patients with anterior circulation ischemic stroke.
Variable Systolic BP Elevated Not Elevated Diastolic BP Elevated Not Elevated
1st day NIHSS Median P (Min-Max) 0.227 5 (2 -13) 4 (1 -17) 0.042 4 (1 - 13) 5 (1 - 17)
7Th day NIHSS 30Th day NIHSS Median P Median P (Min-Max) (Min-Max) 0.441 0.995 3 (1 - 10) 2 (1 - 8) 3 (1 - 16) 2 (1 - 14) 0.006 0.146 2 (1 - 13) 1 (1-11) 4 (1 - 16) 2 (1-14)
Methods
Discussion
• This study took place in a suburban area of Tangerang, Indonesia.
• Our study shows that elevated diastolic blood pressure but not elevated systolic blood pressure was associated with better clinical outcome during the 1st and 7th day. In human subjects, it is known that the regional cerebral blood flow in the ischemic penumbra has been shown to be pressure dependent. A possible explanation is that elevated blood pressure during the acute period of stroke may represent a natural response to promote perfusion and collateral blood flow within the penumbra.
• Patients with acute anterior circulation ischemic stroke were included. • Patients that had thrombolytic treatment were excluded. • Elevated systolic BP (SBP) and diastolic BP (DBP) is defined as BP >180mmHg and >100mmHg respectively. • Clinical outcome was measured using National Institutes of Health Stroke Scale (NIHSS) during the 1st, 7th and 30th day after stroke onset. • Analysis was done using Mann-Whitney. • Ethical clearance was approved by Mochtar Riady Institute for Nanotechnology Ethics Committee (No. 082/MRIN-EC/09/2014).
Results • Total of 92 patients were included, out of which 61 (66.3%) were male. • Median age of patients was 57 (35-89) years. • Elevated SBP had no significant association with 1st (P = 0.227), 7th (P = 0.441) and 30th (P = 0.995) day NIHSS score. • Elevated DBP has significant association with 1st day (P = 0.042) and 7th day (P = 0.006) NIHSS score. • Patients with elevated DBP had lower NIHSS scores during the 1st, 7th and 30th day, but statistically significant only for the 1st and 7th day. Table 1. Baseline Characteristics (n=92) Variable Age (years) [Median (Min-Max)] BMI (kg/m2) [Median (Min-Max)] Gender Male Female Diabetes Mellitus Hypertension Dyslipidemia Smokers or History of Smoking Atrial Fibrillation History of Coronary Artery Disease Random Blood Sugar [Median (Min-Max)] NIHSS Score at Admission [Median (Min-Max)] Infarct Volume (mm3) [Median (Min-Max)] Systolic Blood Pressure > 180mmHg Diastolic Blood Pressure > 100mmHg
57 (35 - 89) 24.2 (17.6 - 35.6) 61 (66.3%) 31 (33.7%) 37 (40.2%) 78 (84.8%) 44 (47.8%) 26 (28.3%) 7 (7.6%) 16 (17.4%) 134.5 (84 -357) 5 (1 -17) 3.25 (0 - 162.6) 22 (23.9%) 30 (32.6%)
• A study by Tziomalos et al showed that elevated diastolic BP at admission is associated with higher risk for in-hospital mortality in hypertensive patients but does not predict the outcome in subjects without a history of hypertension. In contrast, Systolic BP at admission is not associated with in-hospital mortality, regardless of the history of hypertension. Moreover, neither SBP nor DBP at admission predict functional outcome at discharge in either hypertensive patients or in subjects without a history of hypertension. • The strength of this study is that we included only anterior circulation stroke to ensure a homogenous study population. The limitation of our study is that we stratified the numerical variables into categorical variables. • Future recommendations is to see the long term outcome (i.e. 3 months or 1 year outcome) and also to see whether elevated BP during the acute period of stroke can lead to recurrent stroke by following up the patients for a couple of years.
Conclusion Elevated SBP has no significant association with NIHSS score. Elevated DBP has significant association with 1st and 7th day NIHSS score, but not with 30th day NIHSS score. Patients with elevated DBP have better clinical outcome compared to those without elevated DBP. References 1. Kvistad C, Logallo N, Oygarden H, Thomassen L, Waje-Andreassen U, Naess H. Elevated Admission Blood Pressure and Stroke Severity in Acute Ischemic Stroke: The Bergen NORSTROKE Study. Cerebrovascular Diseases. 2013;36(5-6):351-354. 2. McManus M, Liebeskind D. Blood Pressure in Acute Ischemic Stroke. Journal of Clinical Neurology. 2016;12(2):137. 3. Tziomalos K, Giampatzis V, Bouziana S, Spanou M, Papadopoulou M, Kostaki S et al. Elevated Diastolic But Not Systolic Blood Pressure Increases Mortality Risk in Hypertensive But Not Normotensive Patients With Acute Ischemic Stroke. American Journal of Hypertension. 2014;28(6):765-771.
Corresponding Author: Dr. Vivien Puspitasari
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