Midday Dipping and Circadian Blood Pressure Patterns in Acute Ischemic Stroke.

The purpose of this study was to investigate the alterations in blood pressure (BP) during midday and the changes in circadian BP patterns in the acute phase of ischemic stroke (AIS) with the severity of stroke and their predictive role outcomes within 3 months. A total of 228 AIS patients (a prospective multicenter follow-up study) underwent 24 h ambulatory blood pressure monitoring (ABPM). Mean BP parameters during the day (7:00-22:59), the midday (13:00-16:59), and the night (23:00-6:59), and midday and nocturnal dipping were calculated. Midday SBP dippers had less severe stroke, lower incidence of hypertension and SBP/DBP on admission, lower levels of serum glucose and WBCs, and delayed initiation of ABPM compared to risers. There was a reverse relation between midday SBP dipping and both nocturnal dipping and stroke severity. The "double dippers" (midday and nocturnal dipping) had the least severe stroke, the lowest SBP/DBP on admission, the lowest heart rate from ABPM, and a lower risk of an unfavorable outcome, while the "double risers" had the opposite results, by an approximately five-fold risk of death/disability at 3 months. These findings indicate different circadian BP patterns during the acute phase of AIS, which could be considered a marker of stroke severity and prognosis.

Prognostic significance of 24-h blood pressure and variability indices in the outcome of acute ischaemic stroke.

BACKGROUND: The association between blood pressure (BP) levels and BP variability (BPV) following acute ischaemic stroke (AIS) and outcome remains controversial. AIMS: To investigate the predictive value of systolic BP (SBP) and diastolic BP (DBP) and BPV measured using 24-h ambulatory blood pressure monitoring (ABPM) methods during AIS regarding outcome. METHODS: A total of 228 AIS patients (175 without prior disability) underwent ABPM every 20 min within 48 h from onset using an automated oscillometric device (TM 2430, A&D Company Ltd) during day time (7:00-22:59) and night time (23:00-6:59). Risk factors, stroke subtypes, clinical and laboratory findings were recorded. Mean BP parameters and several BPV indices were calculated. End-points were death and unfavourable functional outcome (disability/death) at 3 months. RESULTS: A total of 61 (26.7%) patients eventually died. Multivariate logistic regression analysis revealed that only mean night-time DBP (hazard ratio (HR): 1.04; 95% confidence interval (CI): 1.00-1.07) was an independent prognostic factor of death. Of the 175 patients without prior disability, 79 (45.1%) finally met the end-point of unfavourable functional outcome. Mean 24-h SBP (HR: 1.03; 95% CI: 1.00-1.05), day-time SBP (HR: 1.02; 95% CI: 1.00-1.05) and night-time SBP (HR: 1.03; 95% CI: 1.01-1.05), SBP nocturnal decline (HR: 0.93; 95% CI: 0.88-0.99), mean 24-h DBP (HR: 1.08; 95% CI: 1.03-1.13), day-time DBP (HR: 1.07; 95% CI: 1.03-1.12) and night-time DBP (HR: 1.06; 95% CI: 1.02-1.10) were independent prognostic factors of an unfavourable functional outcome. CONCLUSIONS: In contrast with BPV indices, ABPM-derived BP levels and lower or absence of BP nocturnal decline in the acute phase are prognostic factors of outcome in AIS patients.

Time of blood pressure in target range in acute ischemic stroke.

OBJECTIVE: The purpose of this study was to investigate the association of blood pressure (BP) time-in-target range (TTR) derived from 24-h ambulatory BP monitoring (ABPM) during the acute phase of ischemic stroke (AIS), with the severity of stroke and its predictive value for the 3 months outcome. METHODS: A total of 228 AIS patients (prospective multicenter follow-up study) underwent ABPM every 20 min within 48 h from stroke onset using an automated oscillometric device. Clinical and laboratory findings were recorded. Mean BP parameters, BP variability and TTR for SBP (90-140 mmHg), DBP (60-90 mmHg), and mean arterial pressure (MAP) were calculated. Endpoints were death and disability/death at 3 months. RESULTS: A total of 14 942 BP measurements were recorded (∼66 per AIS patient) within 72 h of stroke onset. Patient's 24-h TTR was 34.7 ±â€Š29.9, 64.3 ±â€Š24.2, and 55.3 ±â€Š29.4% for SBP, DBP and MAP, respectively. In patients without prior hypertension, TTR was lower as stroke severity increased for both DBP (P = 0.031) and MAP (P = 0.016). In 175 patients without prior disability, increase in TTR of DBP and MAP associated significantly with a decreased risk of disability/death (hazard ratio 0.96, 95% CI 0.95-0.99, P = 0.007 and hazard ratio 0.97, 95% CI 0.96-0.99, P = 0.007). TTR of SBP in 130-180 mmHg and 110-160 mmHg ranges seems to be related with mortality and disability outcomes, respectively. CONCLUSION: TTR can be included for a more detailed description of BP course, according to stroke severity, and for the evaluation of BP predictive role, in addition to mean BP values, derived from ABPM during the acute phase of AIS. CLINICAL TRIAL REGISTRATIONURL: http://www.clinicaltrials.gov. Unique identifier: NCT01915862.

Adequacy of preadmission oral anticoagulation with vitamin K antagonists and ischemic stroke severity and outcome in patients with atrial fibrillation.

It is unclear whether vitamin K antagonists affect stroke severity and outcome in patients with atrial fibrillation (AF). We aimed to evaluate this association. We prospectively studied 539 consecutive patients admitted with acute ischemic stroke (41.2 % males, age 78.9 ± 6.6 years). The severity of stroke was assessed at admission with the National Institutes of Health Stroke Scale (NIHSS). The outcome was assessed with dependency rates at discharge (modified Rankin scale 2-5) and with in-hospital mortality. 177 patients had a history of AF. The median NIHSS at admission did not differ between patients on acenocoumarol with INR 2.0-3.0, on acenocoumarol with INR < 2.0, on single antiplatelet treatment, on dual antiplatelet treatment, or on no treatment [4 (range 0-26), 13 (0-39), 8 (0-33), 3 (2-23) and 7 (0-33), respectively; p = 0.433]. Dependency rates were lower in patients on acenocoumarol with INR 2.0-3.0 or on dual antiplatelet treatment than in those on acenocoumarol with INR < 2.0, single antiplatelet treatment, or no treatment (20.0, 22.2, 61.5, 58.7 and 68.0 %, respectively; p = 0.024). Independent predictors of dependency were age, NIHSS at admission and history of ischemic stroke. In-hospital mortality did not differ between patients on acenocoumarol with INR 2.0-3.0, on acenocoumarol with INR < 2.0, on single antiplatelet treatment, on dual antiplatelet treatment, or on no treatment (7.7, 18.2, 16.1, 16.7 and 22.2 %, respectively; p = 0.822). In conclusion, optimally anticoagulated patients with AF have more favorable functional outcome after stroke and a trend for less severe stroke whereas patients with subtherapeutic anticoagulation have similar stroke severity and outcome with those on no treatment.

Prior treatment with dipeptidyl peptidase 4 inhibitors is associated with better functional outcome and lower in-hospital mortality in patients with type 2 diabetes mellitus admitted with acute ischaemic stroke.

It is unclear whether prior antidiabetic treatment affects stroke severity and outcome. To evaluate this association, we prospectively studied all patients who were admitted in our Department with acute ischaemic stroke (n = 378, mean age = 78.8 ± 6.5 years). The severity of stroke was assessed at admission with the National Institutes of Health Stroke Scale. The outcome was assessed with the modified Rankin Scale at discharge and with in-hospital mortality. A total of 123 patients had type 2 diabetes mellitus. At admission, there was a trend for lower National Institutes of Health Stroke Scale in patients treated with dipeptidyl peptidase 4 inhibitors compared with patients treated with other antidiabetic agents (6.1 ± 7.5 vs 10.0 ± 9.2, respectively; p = 0.079). At discharge, patients treated with dipeptidyl peptidase 4 inhibitors had lower modified Rankin Scale than patients treated with other antidiabetic agents (2.1 ± 1.9 vs 3.2 ± 2.1, respectively; p < 0.05). Patients treated with dipeptidyl peptidase 4 inhibitors also had lower in-hospital mortality than patients treated with other antidiabetic agents (0.0% vs 15.1%, respectively; p < 0.05). In conclusion, prior treatment with dipeptidyl peptidase 4 inhibitors in patients with acute ischaemic stroke appears to be associated with better functional outcome and lower mortality risk.

Elevated diastolic but not systolic blood pressure increases mortality risk in hypertensive but not normotensive patients with acute ischemic stroke.

BACKGROUND: The relationship between blood pressure (BP) at admission for acute ischemic stroke and outcome is controversial. We aimed to assess whether only systolic BP (SBP), only diastolic BP (DBP), both or neither predict outcome and whether these associations differ between patients with and without a history of hypertension. METHODS: We prospectively studied all patients who were admitted with acute ischemic stroke (n = 415; 39.5% males, age 78.8 ± 6.6 years). The severity of stroke was assessed at admission with the National Institutes of Health Stroke Scale (NIHSS). The outcome was evaluated with dependency at discharge (modified Rankin scale between 2 and 5) and in-hospital mortality. RESULTS: In the total study population, independent predictors of dependency at discharge were age, history of prior ischemic stroke, and NIHSS score at admission. Independent predictors of in-hospital mortality were DBP at admission and NIHSS score at admission. In patients with a history of hypertension (n = 343), independent predictors of dependency at discharge were age and NIHSS score at admission whereas independent predictors of in-hospital mortality were DBP at admission and NIHSS score at admission. In patients without a history of hypertension (n = 72), the only independent predictor of dependency at discharge and in-hospital mortality was the NIHSS score at admission. CONCLUSIONS: Higher DBP at admission predict in-hospital mortality in patients with acute ischemic stroke whereas SBP in the acute phase is not associated with short-term outcome. The relationship between DBP at admission and outcome appears to be more prominent in hypertensive patients.

Type 2 diabetes is associated with a worse functional outcome of ischemic stroke.

AIM: To assess whether ischemic stroke severity and outcome is more adverse in patients with type 2 diabetes mellitus (T2DM). METHODS: Consecutive patients hospitalized for acute ischemic stroke between September 2010 and June 2013 were studied prospectively (n = 482; 40.2% males, age 78.8 ± 6.7 years). T2DM was defined as self-reported T2DM or antidiabetic treatment. Stroke severity was evaluated with the National Institutes of Health Stroke Scale (NIHSS) score at admission. The outcome was assessed with the modified Rankin scale (mRS) score at discharge and with in-hospital mortality. Adverse outcome was defined as mRS score at discharge ≥ 2 or in-hospital death. The length of hospitalization was also recorded. RESULTS: T2DM was present in 32.2% of the study population. Patients with T2DM had a larger waist circumference, higher serum triglyceride and glucose levels and lower serum high-density lipoprotein cholesterol levels as well as higher prevalence of hypertension, coronary heart disease and congestive heart failure than patients without T2DM. On the other hand, diabetic patients had lower low-density lipoprotein cholesterol levels and reported smaller consumption of alcohol than non-diabetic patients. At admission, the NIHSS score did not differ between patients with and without T2DM (8.7 ± 8.8 and 8.6 ± 9.2, respectively; P = NS). At discharge, the mRS score also did not differ between the two groups (2.7 ± 2.1 and 2.7 ± 2.2 in patients with and without T2DM, respectively; P = NS). Rates of adverse outcome were also similar in patients with and without T2DM (62.3% and 58.5%, respectively; P = NS). However, when we adjusted for the differences between patients with T2DM and those without T2DM in cardiovascular risk factors, T2DM was independently associated with adverse outcome [relative risk (RR) = 2.39; 95%CI: 1.21-4.72, P = 0.012]. In-hospital mortality rates did not differ between patients with T2DM and those without T2DM (9.0% and 9.8%, respectively; P = NS). In multivariate analysis adjusting for the difference in cardiovascular risk factors between the two groups, T2DM was again not associated with in-hospital death. CONCLUSION: T2DM does not appear to affect ischemic stroke severity but is independently associated with a worse functional outcome at discharge.

Increased augmentation index is paradoxically associated with lower in-hospital mortality in patients with acute ischemic stroke.

OBJECTIVE: To evaluate the association between arterial stiffness and stroke severity and in-hospital outcome in patients admitted with acute ischemic stroke. METHODS: We prospectively studied 415 consecutive patients who were admitted with acute ischemic stroke (39.5% males, age 78.8 ± 6.6 years). On the third day of hospitalization, the following markers of arterial stiffness were recorded: central systolic blood pressure (cSBP), diastolic BP (cDBP), mean pressure (cMP), pulse pressure (cPP), augmentation index (AIx) and pulse wave velocity (PWV). The severity of stroke was assessed on admission with the National Institutes of Health Stroke Scale (NIHSS) score. The outcome was evaluated with rates of dependency at discharge (modified Rankin scale score between 2 and 5) and in-hospital mortality. RESULTS: None of the markers of arterial stiffness showed significant correlation with the NIHSS score on admission. However, there was a trend for an inverse correlation with AIx (r = -0.142, p = 0.064) and for a positive correlation with PWV (r = 0.235, p = 0.054). None of the markers of arterial stiffness differed between patients who were dependent at discharge and those who were independent. Patients who died during hospitalization had higher cDBP and cMP but lower cPP and AIx than patients who were discharged. In binary logistic regression analysis, independent predictors of in-hospital mortality were NIHSS score on admission (relative risk (RR) 1.16, 95% confidence interval (CI) 1.08-1.25, p < 0.001), presence of atrial fibrillation (RR 6.41, 95% CI 1.37-29.93, p = 0.018) and AIx (RR 0.94, 95% CI 0.89-0.99, p = 0.030). CONCLUSIONS: Increased AIx appears to be associated with lower in-hospital mortality rates in elderly patients with acute ischemic stroke. Other markers of arterial stiffness do not appear to be associated with short-term outcome in this population.