Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.
ADVANCED SEARCH
Log in
Top
Neurocritical Care

22-04-2024 | Stroke | Original work

Assessment of Blood Pressure and Heart Rate Related Variables in Acute Stroke Patients Receiving Intravenous Antihypertensive Medication Infusions

Authors: Adnan I. Qureshi, William I. Baskett, Abdullah Lodhi, Francisco Gomez, Niraj Arora, Premkumar N. Chandrasekaran, Farhan Siddiq, Camilo R. Gomez, Chi-Ren Shyu

Published in: Neurocritical Care

Login to get access

Abstract

Background

We performed an analysis of a large intensive care unit electronic database to provide preliminary estimates of various blood pressure parameters in patients with acute stroke receiving intravenous (IV) antihypertensive medication and determine the relationship with in-hospital outcomes.

Methods

We identified the relationship between pre-treatment and post-treatment systolic blood pressure (SBP) and heart rate (HR)–related variables and in-hospital mortality and acute kidney injury in patients with acute stroke receiving IV clevidipine, nicardipine, or nitroprusside using data provided in the Medical Information Mart for Intensive Care (MIMIC) IV database.

Results

A total of 1830 patients were treated with IV clevidipine (n = 64), nicardipine (n = 1623), or nitroprusside (n = 143). The standard deviations [SDs] of pre-treatment SBP (16.3 vs. 13.7, p ≤ 0.001) and post-treatment SBP (15.4 vs. 14.4, p = 0.004) were higher in patients who died compared with those who survived, particularly in patients with intracerebral hemorrhage (ICH). The mean SBP was significantly lower post treatment compared with pre-treatment values for clevidipine (130.7 mm Hg vs. 142.5 mm Hg, p = 0.006), nicardipine (132.8 mm Hg vs. 141.6 mm Hg, p ≤ 0.001), and nitroprusside (126.2 mm Hg vs. 139.6 mm Hg, p ≤ 0.001). There were no differences in mean SDs post treatment compared with pre–treatment values for clevidipine (14.5 vs. 13.5, p = 0.407), nicardipine (14.2 vs. 14.6, p = 0.142), and nitroprusside (14.8 vs. 14.8, p = 0.997). The SDs of pre-treatment and post-treatment SBP were not significantly different in patients with ischemic stroke treated with IV clevidipine, nicardipine, or nitroprusside or for patients with ICH treated with IV clevidipine or nitroprusside. However, patients with ICH treated with IV nicardipine had a significantly higher SD of post-treatment SBP (13.1 vs. 14.2, p = 0.0032).

Conclusions

We found that SBP fluctuations were associated with in-hospital mortality in patients with acute stroke. IV antihypertensive medication reduced SBP but did not reduce SBP fluctuations in this observational study. Our results highlight the need for optimizing therapeutic interventions to reduce SBP fluctuations in patients with acute stroke.
Appendix
Available only for authorised users
Literature
1.
Greenberg SM, Ziai WC, Cordonnier C, Dowlatshahi D, Francis B, Goldstein JN, et al.; American Heart Association/American Stroke Association. guideline for the management of patients with spontaneous intracerebral hemorrhage: a guideline from the American Heart Association/American Stroke Association. Stroke. 2022;53(7):e282–361.
2.
Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019;50(12):e344–418.PubMedCrossRef
3.
Moullaali TJ, Wang X, Martin RH, Shipes VB, Robinson TG, Chalmers J, et al. Blood pressure control and clinical outcomes in acute intracerebral haemorrhage: a preplanned pooled analysis of individual participant data. Lancet Neurol. 2019;18(9):857–64.PubMedCrossRef
4.
Castillo J, Leira R, García MM, Serena J, Blanco M, Dávalos A. Blood pressure decrease during the acute phase of ischemic stroke is associated with brain injury and poor stroke outcome. Stroke. 2004;35(2):520–6.PubMedCrossRef
5.
Qureshi AI, Palesch YY, Foster LD, Barsan WG, Goldstein JN, Hanley DF, et al.; ATACH 2 Trial Investigators. Blood pressure-attained analysis of ATACH 2 trial. Stroke. 2018;49(6):1412–8.CrossRef
6.
WHO. Clinical outcomes depending on acute blood pressure after cerebral hemorrhage. Ann Neurol. 2019;85(1):105–13.CrossRef
7.
Moullaali TJ, Wang X, Sandset EC, Woodhouse LJ, Law ZK, Arima H, et al.; Blood Pressure in Acute Stroke (BASC) Investigators. Early lowering of blood pressure after acute intracerebral haemorrhage: a systematic review and meta-analysis of individual patient data. J Neurol Neurosurg Psychiatry. 2022;93(1):6–13.CrossRef
8.
Aslanyan S, Fazekas F, Weir CJ, Horner S, Lees KR AIN International Steering Committee and Investigators. Effect of blood pressure during the acute period of ischemic stroke on stroke outcome: a tertiary analysis of the GAIN International trial. Stroke. 2003;34(10):2420–5.CrossRef
9.
Brott T, Lu M, Kothari R, Fagan SC, Frankel M, Grotta JC, et al. Hypertension and its treatment in the NINDS rt-PA Stroke trial. Stroke. 1998;29(8):1504–9.PubMedCrossRef
10.
Qureshi AI. The importance of acute hypertensive response in ICH. Stroke. 2013;44(6 Suppl 1):S67–9.PubMed
11.
Toyoda K, Yoshimura S, Fukuda-Doi M, Qureshi AI, Inoue M, Miwa K, et al.; ATACH Trial Investigators; SAMURAI Investigators. Intravenous nicardipine for Japanese patients with acute intracerebral hemorrhage: an individual participant data analysis. Hypertens Res. 2023;46(1):75–83.CrossRef
12.
Li Q, Warren AD, Qureshi AI, Morotti A, Falcone GJ, Sheth KN, et al. Ultra-early blood pressure reduction attenuates hematoma growth and improves outcome in intracerebral hemorrhage. Ann Neurol. 2020;88(2):388–95.PubMedPubMedCentralCrossRef
13.
Qureshi AI, Huang W, Lobanova I, Barsan WG, Hanley DF, Hsu CY, et al.; for ATACH-II trial investigators. Outcomes of intensive systolic blood pressure reduction in patients with intracerebral hemorrhage and excessively high initial systolic blood pressure: post hoc analysis of a randomized clinical trial. JAMA Neurol. 2020;77(11):1355–65.CrossRef
14.
Wang R, Liu Y, Yang P, Zhu Z, Shi M, Peng Y, et al. Blood pressure fluctuation during hospitalization and clinical outcomes within 3 months after ischemic stroke. Hypertension. 2022;79(10):2336–45.PubMedCrossRef
15.
Hemphill JC 3rd, Adeoye OM, Alexander DN, Alexandrov AW, Amin-Hanjani S, Cushman M, et al.; AHA/ASA Stroke Performance Oversight Committee. Clinical performance measures for adults hospitalized with intracerebral hemorrhage: performance measures for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018;49(7):e243–61.
16.
Qureshi AI. Intracerebral hemorrhage specific intensity of care quality metrics. Neurocrit Care. 2011;14(2):291–317.PubMedCrossRef
17.
Turlapaty D; IV Nicardipine Study Group. Efficacy and safety of intravenous nicardipine in the control of postoperative hypertension. Chest. 1991;99(2):393–8.CrossRef
18.
Espinosa A, Ripollés-Melchor J, Casans-Francés R, Abad-Gurumeta A, Bergese SD, Zuleta-Alarcon A, et al.; Evidence Anesthesia Review Group. Perioperative use of clevidipine: a systematic review and meta-analysis. PLoS ONE. 2016;11(3):e0150625.CrossRef
19.
Graff B, Gąsecki D, Rojek A, Boutouyrie P, Nyka W, Laurent S, et al. Heart rate variability and functional outcome in ischemic stroke: a multiparameter approach. J Hypertens. 2013;31(8):1629–36.PubMedCrossRef
20.
Sethi A, Callaway CW, Sejdić E, Terhorst L, Skidmore ER. Heart rate variability is associated with motor outcome 3-months after stroke. J Stroke Cerebrovasc Dis. 2016;25(1):129–35.PubMedCrossRef
21.
Tang SC, Jen HI, Lin YH, Hung CS, Jou WJ, Huang PW, et al. Complexity of heart rate variability predicts outcome in intensive care unit admitted patients with acute stroke. J Neurol Neurosurg Psychiatry. 2015;86(1):95–100.PubMedCrossRef
22.
Rudin RS, Friedberg MW, Shekelle P, Shah N, Bates DW. Getting value from electronic health records: research needed to improve practice. Ann Intern Med. 2020;172(11 Suppl):S130–6.PubMedCrossRef
23.
Hatef E. The role of real-time health data and health information technology in reducing diabetes risk and advancing population health. JAMA Netw Open. 2021;4(10):e2130955.PubMedCrossRef
24.
Johnson AE, Pollard TJ, Shen L, Lehman LW, Feng M, Ghassemi M, et al. MIMIC-III, a freely accessible critical care database. Sci Data. 2016;3(1):160035.PubMedPubMedCentralCrossRef
25.
26.
27.
WHO. Intensive blood-pressure lowering in patients with acute cerebral hemorrhage. N Engl J Med. 2016;375(11):1033–43.CrossRef
28.
Anderson CS, Heeley E, Huang Y, Wang J, Stapf C, Delcourt C, et al.; INTERACT2 Investigators. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013;368(25):2355–65.CrossRef
29.
Peacock WF, Varon J, Baumann BM, Borczuk P, Cannon CM, Chandra A, et al. CLUE: a randomized comparative effectiveness trial of IV nicardipine versus labetalol use in the emergency department. Crit Care. 2011;15(3):R157.PubMedPubMedCentralCrossRef
30.
Morfis L, Schwartz RS, Poulos R, Howes LG. Blood pressure changes in acute cerebral infarction and hemorrhage. Stroke. 1997;28(7):1401–5.PubMedCrossRef
31.
Ahmed N, Wahlgren N, Brainin M, Castillo J, Ford GA, Kaste M, et al.; SITS Investigators. Relationship of blood pressure, antihypertensive therapy, and outcome in ischemic stroke treated with intravenous thrombolysis: retrospective analysis from Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register (SITS-ISTR). Stroke. 2009;40(7):2442–9.CrossRef
32.
Parati G, Ochoa JE, Lombardi C, Bilo G. Assessment and management of blood-pressure variability. Nat Rev Cardiol. 2013;10(3):143–55.PubMedCrossRef
33.
Mancia G. Short- and long-term blood pressure variability: present and future. Hypertension. 2012;60(2):512–7.PubMedCrossRef
34.
Bennett AE, Wilder MJ, McNally JS, Wold JJ, Stoddard GJ, Majersik JJ, et al. Increased blood pressure variability after endovascular thrombectomy for acute stroke is associated with worse clinical outcome. J Neurointerv Surg. 2018;10(9):823–7.PubMedCrossRef
35.
Kellert L, Sykora M, Gumbinger C, Herrmann O, Ringleb PA. Blood pressure variability after intravenous thrombolysis in acute stroke does not predict intracerebral hemorrhage but poor outcome. Cerebrovasc Dis. 2012;33(2):135–40.PubMedCrossRef
36.
Yao MX, Qiu DH, Zheng WC, Zhao JH, Yin HP, Liu YL, et al. Effects of early-stage blood pressure variability on the functional outcome in acute ischemic stroke patients with symptomatic intracranial artery stenosis or occlusion receiving intravenous thrombolysis. Front Neurol. 2022;13:823494.PubMedPubMedCentralCrossRef
37.
Zhao J, Yuan F, Fu F, Liu Y, Xue C, Wang K, et al.; CHASE Study Group. Blood pressure variability and outcome in acute severe stroke: a post hoc analysis of CHASE-A randomized controlled trial. J Clin Hypertens (Greenwich). 2021;23(1):96–102.CrossRef
38.
Chung PW, Kim JT, Sanossian N, Starkmann S, Hamilton S, Gornbein J, et al.; FAST-MAG Investigators and Coordinators. Association between hyperacute stage blood pressure variability and outcome in patients with spontaneous intracerebral hemorrhage. Stroke. 2018;49(2):348–54.CrossRef
39.
de Havenon A, Majersik JJ, Stoddard G, Wong KH, McNally JS, Smith AG, et al. Increased blood pressure variability contributes to worse outcome after intracerebral hemorrhage. Stroke. 2018;49(8):1981–4.PubMedPubMedCentralCrossRef
40.
Manning L, Hirakawa Y, Arima H, Wang X, Chalmers J, Wang J, et al.; INTERACT2 investigators. Blood pressure variability and outcome after acute intracerebral haemorrhage: a post-hoc analysis of INTERACT2, a randomised controlled trial. Lancet Neurol. 2014;13(4):364–73.CrossRef
41.
Manning LS, Rothwell PM, Potter JF, Robinson TG. Prognostic significance of short-term blood pressure variability in acute stroke: systematic review. Stroke. 2015;46(9):2482–90.PubMedCrossRef
42.
Qin J, Zhang Z. Prognostic significance of early systolic blood pressure variability after endovascular thrombectomy and intravenous thrombolysis in acute ischemic stroke: a systematic review and meta-analysis. Brain Behav. 2020;10(12):e01898.PubMedPubMedCentralCrossRef
43.
Lees T, Shad-Kaneez F, Simpson AM, Nassif NT, Lin Y, Lal S. Heart rate variability as a biomarker for predicting stroke, post-stroke complications and functionality. Biomark Insights. 2018;13:1177271918786931.PubMedPubMedCentralCrossRef
44.
45.
De Raedt S, De Vos A, De Keyser J. Autonomic dysfunction in acute ischemic stroke: An underexplored therapeutic area? J Neurol Sci. 2015;348(1–2):24–34.PubMedCrossRef
46.
Sykora M, Diedler J, Turcani P, Hacke W, Steiner T. Baroreflex: A new therapeutic target in human stroke? Stroke. 2009;40(12):e678–82.PubMedCrossRef
47.
Kang AR, Lee J, Jung W, Lee M, Park SY, Woo J, et al. Development of a prediction model for hypotension after induction of anesthesia using machine learning. PLoS ONE. 2020;15(4):e0231172.PubMedPubMedCentralCrossRef
48.
49.
Jeong YS, Kang AR, Jung W, Lee SJ, Lee S, Lee M, et al. Prediction of blood pressure after induction of anesthesia using deep learning: a feasibility study. Appl Sci (Basel). 2019;9(23):5135.CrossRef
50.
Alhajji M, Kawsara A, Alkhouli M. Validation of acute ischemic stroke codes using the International Classification of Diseases Tenth Revision. Am J Cardiol. 2020;125(7):1135.PubMedCrossRef
51.
Joos C, Lawrence K, Jones AE, Johnson SA, Witt DM. Accuracy of ICD-10 codes for identifying hospitalizations for acute anticoagulation therapy-related bleeding events. Thromb Res. 2019;181:71–6.PubMedCrossRef
52.
Wu CS, Chen PH, Chang SH, Lee CH, Yang LY, Chen YC, et al. Atrial fibrillation is not an independent determinant of mortality among critically ill acute ischemic stroke patients: a propensity score-matched analysis from the MIMIC-IV database. Front Neurol. 2022;12:730244.PubMedPubMedCentralCrossRef
53.
Sauer CM, Chen LC, Hyland SL, Girbes A, Elbers P, Celi LA. Leveraging electronic health records for data science: common pitfalls and how to avoid them. Lancet Digit Health. 2022;4(12):e893–8.PubMedCrossRef
54.
Qureshi AI, Chaudhry SA, Sapkota BL, Rodriguez GJ, Suri MF. Discharge destination as a surrogate for Modified Rankin Scale defined outcomes at 3- and 12-months poststroke among stroke survivors. Arch Phys Med Rehabil. 2012;93(8):1408–13.PubMedPubMedCentralCrossRef
55.
ElHabr AK, Katz JM, Wang J, Bastani M, Martinez G, Gribko M, et al. Predicting 90-day modified Rankin Scale score with discharge information in acute ischaemic stroke patients following treatment. BMJ Neurol Open. 2021;3(1):e000177.PubMedPubMedCentralCrossRef
56.
Asaithambi G, Tipps ME. Predictive value of discharge destination for 90-day outcomes among ischemic stroke patients eligible for endovascular treatment: post-hoc analysis of DEFUSE 3. J Stroke Cerebrovasc Dis. 2020;29(8):104902.PubMedCrossRef
Metadata
Title
Assessment of Blood Pressure and Heart Rate Related Variables in Acute Stroke Patients Receiving Intravenous Antihypertensive Medication Infusions
Authors
Adnan I. Qureshi
William I. Baskett
Abdullah Lodhi
Francisco Gomez
Niraj Arora
Premkumar N. Chandrasekaran
Farhan Siddiq
Camilo R. Gomez
Chi-Ren Shyu
Publication date
22-04-2024
Publisher
Springer US
Published in
Neurocritical Care
Print ISSN: 1541-6933
Electronic ISSN: 1556-0961
DOI
https://doi.org/10.1007/s12028-024-01974-8