Letter by Mulder et al Regarding Article, "2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: a Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association".
Letter by Mulder et al Regarding Article, "2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: a Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association".
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DOI：
10.1161/strokeaha.118.021270
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发表时间：
2019-06
期刊：
影响因子：
8.3
通讯作者：
M. Mulder;Hester F. Lingsma;D. Dippel
中科院分区：
文献类型：
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作者：
M. Mulder;Hester F. Lingsma;D. Dippel
我们认为这两种选择都可能是有害的。降低血压需要宝贵的时间，正如1993年所说的那样：“时间就是大脑！”2当前指南更新也强调了这一点，".应避免任何延迟机械血栓切除术的原因，包括观察静脉注射阿替普酶后的临床反应。”第二，确实没有令人信服的证据表明EVT在高血压患者中的益处和安全性，因为大多数证明EVT益处的随机对照试验排除了血压> 185/110 mm Hg的患者。相反，也没有证据表明EVT对这些患者没有益处或不安全; BP与EVT的相互作用从未得到证实。3这与静脉溶栓一致，静脉溶栓中血压不影响治疗有效性或安全性。4.两种急性再灌注治疗均未发现相互作用，这一事实强调，急性缺血性卒中的血压可被视为预后因素，但不是影响静脉溶栓或EVT相对效果的预测因素。因此，现有数据未提供BP阈值的依据。最后，急性降低近端血管闭塞的缺血性卒中患者的血压也可能是有害的，正如Fischer和Mattle最近在该杂志中所述：“在灌注已经受损的情况下，快速降低血压可能会损害血流。此外，在持续性血管闭塞的缺血性卒中中，降低血压可能会减少侧支血流。由于血压自动调节受到干扰，血压降低将减少半暗带灌注，这可能加速半暗带组织的损失并迅速增加梗死核心。5总之，考虑到现有的证据，关于EVT候选者的高血压管理的建议如下：“没有证据表明延迟或停止高血压患者的EVT。”
We think both options could be potentially harmful. Lowering BP takes valuable time and as was already stated in 1993:“Time is brain!” 2 This was also emphasized by the current guideline update,“… any cause for delay to mechanical thrombectomy, including observing for a clinical response after intravenous alteplase, should be avoided.” 1 Second, it is true that there is no convincing evidence of EVT benefit and safety in high BP patients, because most randomized controlled trials that demonstrated the benefit of EVT excluded patients with a BP> 185/110 mm Hg. On the contrary, there is also no evidence that EVT is of no benefit or unsafe in these patients; an interaction of BP with EVT has never been demonstrated. 3 This is consistent with intravenous thrombolysis, where it is also known that BP does not affect treatment effectiveness or safety. 4 The fact that no interaction is found with both acute reperfusion therapies emphasizes that BP in acute ischemic stroke can be considered a prognostic factor for outcome but not a predictive factor that influences the relative effect of intravenous thrombolysis or EVT. Therefore, the available data provide no rationale for a BP threshold. Lastly, acutely lowering BP in ischemic stroke patients with proximal vessel occlusion could also be harmful, as recently stated by Fischer and Mattle in this journal:“rapid BP lowering could compromise blood flow at a time when perfusion is already compromised. Furthermore, in ischemic stroke with persistent vessel occlusion lowering of BP is likely to decrease collateral flow. Because BP autoregulation is disturbed, BP lowering would reduce penumbral perfusion, which could accelerate loss of penumbral tissue and increase the core of the infarct rapidly.” 5 In conclusion, considering the available evidence, the recommendation regarding high BP management in EVT candidates should be as follows:“There is no evidence to delay or withhold EVT in patients with high BP.”