intern talk - bp and stroke
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Intern TalkNicholas Reynolds
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Introduction
•BP increased in stroke and usually decreases spontaneously over time
•BP higher in patients with acute stroke than other acute illnesses
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However
•High BP more common in individuals with stroke than general population
•A) High post-stroke BP
•B) Blood pressure variability
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Causes for increased post-
stroke HTN•Disturbed autoregulation
•autonomic reactivity
•neuroendocrine factors
•headache, urinary retention, etc.
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Troubling point
•The reduction of blood pressure after acute stroke is of no benefit or slight harm: ischemic stroke
•Some benefit: intracerebral hemorrhage
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Troubling point
•No clear physiological explanation for these findings
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Hypothesis
•Post-stroke hypertension due to recent premorbid increase in blood pressure
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Design
•Oxfordshire from 2002 to 2012
•Determine relation between premorbid and acute post-event blood pressure in two stroke subtypes in oxford vascular study
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Design
•post-stroke BP
•NIHSS stroke scale >3
•TOAST (Trial of Org 10172 in Acute ischemic stroke treatment) for subtype classification
•European guidelines lowered BP only if >220 mmHg systolic or >120 mmHg diastolic
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Analysis•1st event only
•Exclusion: TIA, minor stroke (NIH <3)
•mean 10 yr premorbid BP, highest premorbid BP, visit-visit variability, coefficient of variation, variation independent mean
•log(time scale)
•pre-event to post-event comparision using paired t test
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Results•636 eligible patient
•median premorbid BP measurement: 17 (8-31 IRQ)
•positive correlation between number premorbid readings and mean premorbid systolic BP
•mean premorbid systolic BP > ischemic stroke (6.5 mmHg CI 0.5-12)
•mean premorbid visit-visit variability SD 16-89 vs 15-13 mmHg) ischemic vs. hemorrhagic
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Results
•most recent premorbid systolic BP in ischemic stroke no greater in period before stroke BUT systolic BP higher in weeks and days before intracranial hemorrhage
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Discussion
•premorbid systolic BP increased in patients with intracerebral hemorrhage substantially following stroke
•no difference for ischemic stroke
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Discussion
•Post-stroke BP higher than most recent premorbid BP suggesting post-stroke factors leading to rise - cushing’s response, stress
•Odd this not seen in ischemic stroke
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Discussion
•Explanation of equivocal findings of BP reduction in ischemic stroke
•Highlight need for long-term BP control especially in prevention of intracerebral hemorrhage
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Limitations
•Late presentation
•Post stroke use of antihypertensives
•Measurement error
•no systemic protocol for recording
•exclusions for TIA, minor stroke
•Biphasic intracerebellar hemorrhage peak suggests a mechanism
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