The Magnitude of Blood Pressure Reduction Predicts Poor In-Hospital Outcome in Acute Intracerebral Hemorrhage
The Magnitude of Blood Pressure Reduction Predicts Poor In-Hospital Outcome in Acute Intracerebral Hemorrhage
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DOI：
10.1007/s12028-020-01016-z
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发表时间：
2020-06-10
影响因子：
3.5
通讯作者：
Di Napoli, Mario
中科院分区：
文献类型：
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作者：
Diyani, Afshin A.;Liu, Xi;Di Napoli, Mario
背景 早期收缩压 (SBP) 降低被认为可以改善自发性脑出血 (ICH) 后的预后，但对个体患者的 SBP 轨迹评估有限。我们的目的是确定 ICH 中 SBP 轨迹的预后意义。方法 我们收集了两个医疗系统 10 年来自发性脑出血患者的常规数据。使用无监督功能主成分分析 (FPCA) 来描述前 24 小时内的 SBP 轨迹及其与出院时改良 Rankin 量表 (mRS) 不利转变的主要结果的关系，分类为序数三分变量（mRS 0-2、3-4 和 5-6 分别定义为良好、差和严重）。根据基线 SBP 和 ICH 体积调整的有序逻辑回归模型用于确定 SBP 轨迹的预后意义。结果 该研究纳入的 757 名患者年龄为 65 +/- 23 岁，其中 56% 为男性，格拉斯哥评分中位数 (IQR) 为 14 (8)。 FPCA 显示，24 小时内的平均 SBP 和前 6 小时内的 SBP 降低占 SBP 轨迹变化的 76.8%。 SBP 降低（每 10 mmHg）的增加与定义为 mRS > 2 的不利结果显着相关（调整后 OR = 1.134；95% CI 1.044-1.233，P = 0.003）。与收缩压降低 < 20 mmHg 相比，收缩压降低 = 40-60 mmHg（调整后 OR = 1.940，95% CI 1.129-3.353，P = 0.017）和 > 60 mmHg（调整后 OR = 1.965，95% CI 1.011，3.846，P = 0.047）。此外，收缩压降低和结果的关联根据初始血肿量而变化。对于小型（< 7.42 mL）和中型（>= 7.42 且 < 30.47 mL）血肿，较小的 SBP 降低与良好结局（mRS 0-2）相关。此外，虽然血肿较大（≥ 30.47 mL）的患者获得良好结果的可能性较低，但较小的 SBP 降低与严重结果概率的降低相关（mRS 5-6）。结论 我们的分析表明，前 6 小时 SBP 降低与院内结局显着相关，院内结局随初始血肿量而变化，早期 SBP 降低 > 40 mmHg 对 ICH 患者可能有害。为了使早期收缩压降低产生有效的治疗效果，应考虑目标水平和最佳收缩压降低目标与血肿量的关系。
Background Early systolic blood pressure (SBP) reduction is believed to improve outcome after spontaneous intracerebral hemorrhage (ICH), but there has been a limited assessment of SBP trajectories in individual patients. We aimed to determine the prognostic significance of SBP trajectories in ICH. Methods We collected routine data on spontaneous ICH patients from two healthcare systems over 10 years. Unsupervised functional principal components analysis (FPCA) was used to characterize SBP trajectories over first 24 h and their relationship to the primary outcome of unfavorable shift on modified Rankin scale (mRS) at hospital discharge, categorized as an ordinal trichotomous variable (mRS 0-2, 3-4, and 5-6 defined as good, poor, and severe, respectively). Ordinal logistic regression models adjusted for baseline SBP and ICH volume were used to determine the prognostic significance of SBP trajectories. Results The 757 patients included in the study were 65 +/- 23 years old, 56% were men, with a median (IQR) Glasgow come scale of 14 (8). FPCA revealed that mean SBP over 24 h and SBP reduction within the first 6 h accounted for 76.8% of the variation in SBP trajectories. An increase in SBP reduction (per 10 mmHg) was significantly associated with unfavorable outcomes defined as mRS > 2 (adjusted-OR = 1.134; 95% CI 1.044-1.233,P = 0.003). Compared with SBP reduction < 20 mmHg, worse outcomes were observed for SBP reduction = 40-60 mmHg (adjusted-OR = 1.940, 95% CI 1.129-3.353,P = 0.017) and > 60 mmHg, (adjusted-OR = 1.965, 95% CI 1.011, 3.846,P = 0.047). Furthermore, the association of SBP reduction and outcome varied according to initial hematoma volume. Smaller SBP reduction was associated with good outcome (mRS 0-2) in small (< 7.42 mL) and medium-size (>= 7.42 and < 30.47 mL) hematomas. Furthermore, while the likelihood of good outcome was low in those with large hematomas (>= 30.47 mL), smaller SBP reduction was associated with decreasing probability of severe outcome (mRS 5-6). Conclusion Our analyses suggest that in the first 6 h SBP reduction is significantly associated with the in-hospital outcome that varies with initial hematoma volume, and early SBP reduction > 40 mmHg may be harmful in ICH patients. For early SBP reduction to have an effective therapeutic effect, both target levels and optimum SBP reduction goals vis-a-vis hematoma volume should be considered.