Ischemic stroke and blood pressure
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Blood Pressure Management in Acute Ischemic Stroke: Insights and Implications
Elevated Blood Pressure in Acute Ischemic Stroke
Elevated blood pressure (BP) is a common occurrence in the acute phase of ischemic stroke, often presenting as a sudden rise in BP levels . This elevation is associated with poor functional outcomes and increased mortality . The relationship between high BP and adverse outcomes such as death, dependency, and deterioration has been well-documented, with studies showing significant associations between elevated mean arterial BP (MABP), systolic BP (SBP), and diastolic BP (DBP) with these negative outcomes.
Blood Pressure Lowering: Neutral Effects on Outcomes
Despite the prevalence of high BP in acute ischemic stroke, the strategy for managing it remains controversial. A meta-analysis of randomized controlled trials found that early BP lowering did not significantly affect the risk of death or dependency at three months or at the trial endpoint. Similarly, BP lowering had a neutral effect on recurrent vascular events, disability, all-cause mortality, recurrent stroke, and serious adverse events. These findings suggest that aggressive BP lowering in the early stages of ischemic stroke may not provide the expected benefits.
Complexity of Blood Pressure Management
The management of BP in acute ischemic stroke is complex due to the diverse mechanisms influencing BP changes, which vary over time and across patients. Observational studies have shown that both extremes of BP and high BP variability are linked to worse outcomes . The optimal BP management strategy must consider individual patient factors, including the presence of arterial hypertension and comorbid organ dysfunction.
Blood Pressure and Reperfusion Strategies
Recent studies have highlighted the importance of BP control in the context of reperfusion therapies such as mechanical thrombectomy (MT). Higher pre- and post-MT SBP levels have been associated with increased mortality and lower odds of functional independence at three months. This underscores the need for careful BP management before, during, and after reperfusion procedures to optimize patient outcomes .
Long-Term Blood Pressure Trajectories
The long-term trajectory of BP after acute ischemic stroke also plays a crucial role in patient outcomes. A study identified four distinct BP trajectory groups over one year, with persistently high and slowly dropping SBP trajectories associated with higher risks of adverse cardiovascular outcomes. This indicates that sustained BP management beyond the acute phase is essential for improving long-term outcomes.
Blood Pressure Variability and Stroke Subtypes
BP variability (BPV) has been shown to differ among ischemic stroke subtypes. Higher systolic BP and BPV during the 24-hour period, as well as nighttime diastolic BP, were independent predictors for large-artery atherosclerosis stroke. Increased nighttime diastolic BPV was also an independent risk factor for cardioembolic stroke. These findings highlight the need for tailored BP management strategies based on stroke subtype and BPV patterns.
Conclusion
Managing BP in acute ischemic stroke is a multifaceted challenge that requires a nuanced approach. While early BP lowering has shown neutral effects on immediate outcomes, the complexity of BP changes and their impact on long-term recovery necessitates individualized treatment protocols. Further research is needed to refine these strategies and improve patient outcomes across different stroke subtypes and treatment contexts.
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