Association Between Blood Pressure Control and Risk of Recurrent Intracerebral Hemorrhage.
Association Between Blood Pressure Control and Risk of Recurrent Intracerebral Hemorrhage.
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DOI：
10.1001/jama.2015.10082
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发表时间：
2015-09-01
期刊：
影响因子：
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通讯作者：
Rosand J
中科院分区：
文献类型：
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作者：
Biffi A;Anderson CD;Battey TW;Ayres AM;Greenberg SM;Viswanathan A;Rosand J
脑出血(ICH)是中风最严重的形式。幸存者有很高的复发、死亡和不断恶化的功能残疾的风险。目的：探讨脑出血后血压与脑出血复发风险的关系。对1994年7月至2013年12月连续2197名脑出血患者中的1145名进行了单部位三级护理转诊中心的观察性研究。共有1145名脑出血患者存活至少90天，并被随访至2013年12月(中位数随访时间为36.8个月[至少9.8个月])。在3、6、9、12个月及之后每6个月测量一次血压，由医务人员(住院或门诊医务人员或护理人员)或通过患者自我报告获得。暴露的特征有三个方面：(1)记录的收缩和舒张期测量；(2)根据美国心脏协会/美国中风协会的建议将血压控制适当或不足进行分类；(3)根据国家高血压预防、检测、评估和治疗联合委员会7标准划分高血压的阶段。复发性脑出血及其在脑内的位置(脑叶与非脑叶)。505例脑叶出血幸存者中102例复发脑出血事件，640例非叶脑出血幸存者中44例复发脑出血事件。在随访期间，625名患者在至少一次测量中实现了足够的血压控制(占总范围的54.6%，49.2%-58.7%)，495名患者(即，在所有可用的时间点)实现了一致的血压控制(占总[范围，34.5%-51.0%])。在血压控制不足的患者中，大叶性脑出血的发生率为84/1000人年，而在血压控制适当的患者中，这一发生率为49/1000人年。对于非叶性脑出血，血压控制不足的事件发生率为52/1000人年，而血压控制适当的患者为27/1000人年。在将血压控制建模为时变变量的分析中，血压控制不足与脑叶脑出血(危险比[HR]，3.53[95%CI，1.65-7.54])和非叶脑出血(HR，4.23[95%CI，1.02-17.52])的复发风险增加相关。随访期间的收缩压与脑叶脑出血复发的风险增加(HR，每10 mm Hg升高1.33[95%CI，1.02-1.76])和非叶ICH复发(HR，1.54[95%CI，1.03-2.30])相关。舒张压与非叶ICH复发风险增加相关(HR，每10 mm Hg升高1.21[95%CI，1.01-1.47])，但与叶ICH复发无关(HR，1.36[95%CI，0.90-2.10])。在这项对脑出血幸存者进行的观察性单中心队列研究中，报告的血压测量表明，随访期间血压控制不足与脑叶和非脑叶脑出血复发的风险较高相关。这些数据表明，需要随机临床试验来解决脑出血幸存者更严格的血压控制的好处和风险。
Intracerebral hemorrhage (ICH) is the most severe form of stroke. Survivors are at high risk of recurrence, death, and worsening functional disability. To investigate the association between blood pressure (BP) after index ICH and risk of recurrent ICH. Single-site, tertiary care referral center observational study of 1145 of 2197 consecutive patients with ICH presenting from July 1994 to December 2013. A total of 1145 patients with ICH survived at least 90 days and were followed up through December 2013 (median follow-up of 36.8 months [minimum, 9.8 months]). Blood pressure measurements at 3, 6, 9, and 12 months, and every 6 months thereafter, obtained from medical personnel (inpatient hospital or outpatient clinic medical or nursing staff) or via patient self-report. Exposure was characterized in 3 ways: (1) recorded systolic and diastolic measurements; (2) classification as adequate or inadequate BP control based on American Heart Association/American Stroke Association recommendations; and (3) stage of hypertension based on Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 7 criteria. Recurrent ICH and its location within the brain (lobar vs nonlobar). There were 102 recurrent ICH events among 505 survivors of lobar ICH and 44 recurrent ICH events among 640 survivors of nonlobar ICH. During follow-up adequate BP control was achieved on at least 1 measurement by 625 patients (54.6% of total [range, 49.2%-58.7%]) and consistently (ie, at all available time points) by 495 patients (43.2% of total [range, 34.5%-51.0%]). The event rate for lobar ICH was 84 per 1000 person-years among patients with inadequate BP control compared with 49 per 1000 person-years among patients with adequate BP control. For nonlobar ICH the event rate was 52 per 1000 person-years with inadequate BP control compared with 27 per 1000 person-years for patients with adequate BP control. In analyses modeling BP control as a time-varying variable, inadequate BP control was associated with higher risk of recurrence of both lobar ICH (hazard ratio [HR], 3.53 [95% CI, 1.65-7.54]) and nonlobar ICH (HR, 4.23 [95% CI, 1.02-17.52]). Systolic BP during follow-up was associated with increased risk of both lobar ICH recurrence (HR, 1.33 per 10-mm Hg increase [95% CI, 1.02-1.76]) and nonlobar ICH recurrence (HR, 1.54 [95% CI, 1.03-2.30]). Diastolic BP was associated with increased risk of nonlobar ICH recurrence (HR, 1.21 per 10-mm Hg increase [95% CI, 1.01-1.47]) but not with lobar ICH recurrence (HR, 1.36 [95% CI, 0.90-2.10]). In this observational single-center cohort study of ICH survivors, reported BP measurements suggesting inadequate BP control during follow-up were associated with higher risk of both lobar and nonlobar ICH recurrence. These data suggest that randomized clinical trials are needed to address the benefits and risks of stricter BP control in ICH survivors.