Blood pressure management in patients receiving rescue stenting after failed endovascular treatment in large vessel occlusion acute ischaemic stroke: a multicentre registry

Objective: To investigate the relationship between blood pressure trajectories and blood pressure variability with the risk of target organ damage in Chinese population from childhood to middle age. Methods: This study is a population-based, long-term follow-up cohort study. Participants who had their blood pressure measured at least 5 times in the Hanzhong Adolescent hypertension cohort from 1987 to 2023 were included in this study. Group-based trajectory modeling was used to identify different systolic and diastolic blood pressure trajectories, and the subjects were divided into low-increasing group, moderate-increasing group and high-increasing group according to blood pressure trajectories. Blood pressure variability was assessed using standard deviation (SD), variability independent of the mean (VIM), and average real variability (ARV). Target organ damage was evaluated during the final follow-up in 2023 (middle age). Logistic regression models were used to analyze the relationship between blood pressure trajectories and blood pressure variability with the risk of target organ damage. Results: A total of 2 447 subjects were included, with a median age of 48 years, of whom 1 373 were male (56.1%). Based on systolic blood pressure, 868 were in the low-increasing group, 1 238 in the moderate-increasing group, and 341 in the high-increasing group. For diastolic blood pressure, the distribution was 894, 1 263 and 290, respectively. Compared with the low-increasing group of systolic blood pressure, the moderate-increasing group (arteriosclerosis: OR=4.14, 95%CI 2.96-5.79; proteinuria: OR=2.06, 95%CI 1.38-3.07; left ventricular hypertrophy: OR=1.68, 95%CI 1.00-2.82) and high-increasing group (arterial stiffness: OR=15.44, 95%CI 10.14-23.50; proteinuria: OR=5.80, 95%CI 3.63-9.29; left ventricular hypertrophy: OR=2.93, 95%CI 1.55-5.53) had a higher risk of target organ damage (all P<0.005). The moderate-increasing group of diastolic blood pressure had a higher incidence of arterial stiffness (OR=3.72, 95%CI 2.69-5.12) and proteinuria (OR=1.67, 95%CI 1.15-2.42) than the low-increasing group (all P<0.005), while the high-increasing group had a significantly higher risk of all type of target organ damage compared to the low-increasing group (arterial stiffness: OR=10.84, 95%CI 7.08-16.61; proteinuria: OR=3.72, 95%CI 2.31-5.99; left ventricular hypertrophy: OR=2.38, 95%CI 1.23-4.59; all P<0.005). Additionally, higher systolic blood pressure variability was associated with an increased incidence of arterial stiffness (SD: OR=2.25, 95%CI 1.96-2.57; VIM: OR=1.64, 95%CI 1.45-1.86; ARV: OR=1.70, 95%CI 1.50-1.93) and proteinuria (SD: OR=1.65, 95%CI 1.44-1.89; VIM: OR=1.41, 95%CI 1.22-1.63; ARV: OR=1.45, 95%CI 1.26-1.67; all P<0.005). The results for diastolic blood pressure variability indicators were similar to those for systolic blood pressure. Conclusion: Early-life blood pressure trajectories are predictive of target organ damage risk in middle age. Higher blood pressure variability is related to an increased risk of arterial stiffness and proteinuria, but was less associated with left ventricular hypertrophy. Focusing on the risk of high blood pressure early in life can help prevent the occurrence of target organ damage in middle age.

The Need to Reduce Variability in the Study of Blood Pressure Variability

Background: Blood pressure (BP) variability relates to cardiovascular (CV) diseases and one unexplored mechanism may involve hypertensive peaks caused by high BP variability. To test this hypothesis, we studied the association of cumulative hypertensive peaks (CHP) in 24-h systolic BP with CV risk. Methods: A total of 1212 participants from the Maracaibo Aging Study (mean age, 66; women, 67.2%) underwent 24-h ambulatory BP monitoring and were followed between 1998 and 2010. BP variability was the 24-h average real variability (ARV). CHP in systolic BP (expressed as %) was the number of systolic BP measures ≥125 mmHg (based on the ACC/AHA threshold) each participant experienced over 24-h divided by the number of recordings. The primary endpoint was a composite of fatal and nonfatal coronary, heart failure, and stroke events, while secondary endpoints were total and CV mortality, and fatal and nonfatal coronary and stroke endpoints. Statistics included adjusted Cox proportional models adjusted. Results: During a median follow-up of 8 years, 242 participants developed a composite of any CV endpoint, and 353 died (210 cardiovascular deaths), 129 had coronary and 57 stroke endpoints. An increment of +2 mmHg in 24-h ARV (HR [hazard ratio], 1.18; 95% confidence interval [CI], 1.05-1.33) or +5% in CHP (HR, 1.05; 95% CI, 1.02-1.07) increased CV risk. The inclusion of both indexes in the same Cox proportional models resulted in CHP, but not ARV ( P =0.075), associated with the primary endpoints ( P =0.004). For secondary endpoints, the association of ARV attenuated while CHP was similar. Conclusions: In this population-based cohort study, CHP in 24-h systolic BP explains the association of high 24-h BP variability and CV risk. Clinical management of high 24-h BP variability is challenging but recognizing that an increased variability results in CHP seems a feasible alternative to address in CV prevention.

“Time rate” of 24‐hour blood pressure variability

Higher blood pressure variability (BPV) has been proven associated with worse functional outcome after endovascular treatment (EVT). However, this association is not established according to different stroke etiologies. In this study, we compared patients with the two highest proportions of stroke etiologies-cardioembolism (CE) and large-artery atherosclerosis (LAA), aiming to explore appropriate strategies of BP management for different etiologies. We enrolled patients with large vessel occlusion (LVO) in anterior circulation who underwent EVT and achieved successful recanalization retrospectively. 24-h blood pressure (BP) and BPV measured as blood pressure reduction (BPr), standard deviation (SD), coefficient of variation (CV), successive variation (SV), average real variability (ARV) after EVT were collected for systolic blood pressure (SBP) and diastolic blood pressure (DBP). The favorable outcome was defined as functional independence by 90-day modified Rankin Scale (mRS 0-2). In our cohort, higher BPV parameters significantly resulted in 90d functional dependence in CE-LVO patients (SBPSV OR: 1.083, 95%CI = 1.009-1.163; SBPARV OR: 1.121, 95%CI = 1.019-1.233; DBPSD OR: 1.124, 95%CI = 1.007-1.1256; DBPCV OR: 1.078, 95%CI = 1.002-1.161). However, for LAA-LVO patients, no positive results correlated 90d functional dependence with 24-hour BPV. Additionally, 90d functional dependence in CE patients with poor collaterals were significantly dependent on post-procedural BPV (DBPmax OR: 1.044, 95%CI = 1.002-1.087; DBPSD OR: 1.229, 95%CI = 1.022-1.1.479; DBPCV OR: 1.143, 95%CI = 1.009-1.295). Whereas to patients with good collaterals, there did not exist such a correlation. In summary, stroke etiologies should probably be taken into consideration to optimize individualized BP management strategies. In order to achieve better clinical outcomes for patients with acute ischemic stroke due to large vessel occlusion, stricter blood pressure management should be taken in cardioembolic stroke patients in contrast with large artery atherosclerotic stroke patients after successful endovascular therapy.

sponsorship: The European Union (HEALTH-F7-2011-278249 EU-MASCARA, HEALTH-F7-305507 HOMAGE and the European Research Council Advanced Researcher Grant 294713 EPLORE) and the Fonds voor Wetenschappelijk Onderzoek Vlaanderen, Ministry of the Flemish Community, Brussels, Belgium (G.0881.13 and G.0880.13) currently support the Studies Coordinating Centre (Leuven, Belgium). (European Union|HEALTH-F7-2011-278249 EU-MASCARA, European Union|HEALTH-F7-305507 HOMAGE, European Union (European Research Council)|294713 EPLORE, Fonds voor Wetenschappelijk Onderzoek Vlaanderen, Ministry of the Flemish Community, Brussels, Belgium|G.0881.13, Fonds voor Wetenschappelijk Onderzoek Vlaanderen, Ministry of the Flemish Community, Brussels, Belgium|G.0880.13)

Blood pressure (BP) variability (BPV) is an independent predictor of cardiovascular (CV) events. The role of BPV in defining risk of cancer therapy-related cardiovascular toxicity (CTR-CVT) is currently unknown. The aims of this study were: (i) to evaluate BPV in a population of patients with Multiple Myeloma, undergoing proteasome inhibitors therapy; (ii) to assess the predictive value of BPV for CTR-CVT; (iii) to analyze clusters of subjects based on BPV. One hundred twenty-four patients underwent a baseline evaluation, including Ambulatory Blood Pressure Monitoring (ABPM), PWV, and Echocardiography. BPV was assessed through ABPM-based standard deviation (SD), weighted standard deviation (wSD), coefficient of variation (CoV), average real variability (ARV), and variability independent of the mean (VIM). Individuals who developed CTR-CVT had a higher baseline BPV. Furthermore, night-time BPV was associated with CTR-CVT, independently of age, smoking, BP, diabetes, dyslipidemia, and kidney function (night-time systolic CoV: adjusted OR 1.09 [1.01-1.21]; night-time systolic VIM: adjusted OR 1.18 [1.01-1.39]). Cut-offs for these BPV parameters were identified as predictors of CTR-CVT occurrence: 10.5 for night-time systolic CoV; 7.8 and 6.4 for systolic and diastolic night-time VIM. Clustering analysis identified subgroups of subjects characterized by the highest BPV, who had a greater prevalence of events, but no differences in other CV risk determinants. Short-term BPV is an independent predictor of CTR-CVT. BPV may enhance the precision of risk stratification in cancer patients, enabling identification of individuals at higher risk who would not be recognized, if traditional prognostic indicators were the sole applied criteria. On the left panel in the figure, the distribution of blood pressure variability (BPV) in the population according to cancer therapy-related cardiovascular toxicity occurrence; in the central panel, association of blood pressure variability with events and cutoffs values; in the right panel, clustering analysis results based on BPV levels. Histogram and radar plot represent events and BPV indexes distribution in the three clusters, respectively. ARV, average real variability; BPV, Blood Pressure Variability; CTR-CVT, cancer therapy-related cardiovascular toxicity; CoV, coefficient of variation; DBP, Diastolic blood pressure; SBP, Systolic blood pressure; SD, standard deviation; VIM, variability independent of the mean; wSD, weighted standard deviation.

Introduction: High blood pressure variability (BPV) after endovascular thrombectomy is associated with post-stroke complications and poor neurological outcomes. However, whether BPV is an epiphenomenon of the stroke itself or causally related to the outcome remains unknown. Objective: In this study we aimed to evaluate if a relationship exists between pre-and post-stroke BPV in patients with large vessel occlusions (LVO). Methods: From our prospective stroke registry, we identified patients who had an anterior circulation LVO, underwent EVT, and had at least three blood pressure measurements recorded in the electronic medical record in the six months prior to their stroke admission. All patients had repeated time-stamped blood pressure data recorded for the first 72 hours after thrombectomy. Using the standard deviation of systolic BP, we calculated BPV for each patient and separated patients into tertiles based on their post-EVT BPV. The relationship between pre-stroke BPV and post-EVT BPV was analyzed using an ordinal logistic regression and Spearman’s rank correlation analysis. Results: Two hundred fifty-two patients were included in our analysis (mean age 70±16.2 years, mean admission NIHSS 15±7, median pre-stroke BP measurements 14.5 (IQR 5.0-55.8)). Pre-stroke BPV gradually increased for patients with higher post-EVT BPV tertiles (tertile 1 = 13.2(±5.2) mmHg, tertile 2 = 15.0(±5.5) mmHg, tertile 3 = 16.7(±7.0) mmHg, p=0.001). A positive correlation was observed between pre-stroke BPV and post-EVT BPV (p&lt;0.001, R=0.21). After adjusting for age and admission NIHSS, pre-stroke BPV was significantly associated with post-EVT BPV tertile membership (OR 1.37, 95% CI 1.02-1.86, p=0.039). Conclusion: High pre-stroke BPV is correlated with high post-EVT BPV. Although larger, prospective studies are needed to provide definitive evidence of this relationship, our work suggests that high post-EVT BPV may be related to an underlying biological phenomenon and not merely a consequence of the stroke itself. Individuals with high BPV may benefit from more intensive blood pressure management in the acute phase after EVT.

Introduction: Both increased blood pressure (BP) variability and impaired autoregulation have been associated with increased risk of poor outcome after endovascular thrombectomy (EVT). The combined effect of these two variables, however, has not yet been elucidated. We hypothesized that the detrimental effects of high BP variability may be amplified by impaired autoregulation. Methods: We prospectively enrolled patients with large-vessel occlusion (LVO) stroke undergoing EVT. Autoregulatory function was continuously measured for up to 48 hours post-EVT by interrogating changes in near-infrared spectroscopy-derived tissue oxygenation (a cerebral blood flow surrogate) in response to changes in BP (Fig. 1A). BP variability was assessed using the standard deviation of the mean. Values were averaged for the entire recording period and dichotomized based on the median. Functional outcome was assessed using the modified Rankin scale (mRS) at 90 days. We examined the association between BP variability, autoregulatory function, and outcome using ordinal logistic regression, adjusting for age and admission NIHSS. Results: Ninety-five patients (mean age 71, NIHSS 14, monitoring time 28±18 hours) were included. BP variability (p=0.043) and autoregulation (p=0.04) were each independently associated with functional outcome. Among patients with high BP variability, worse autoregulation was independently associated with higher (worse) mRS scores at 90 days (OR 3.9, 95% CI 1.1-14.5, p=0.036; Fig. 1B). The proportion of favorable outcome was highest among patients with low BP variability and better autoregulation, and lowest among those with high BP variability and worse autoregulation (p=0.073; Fig. 1C). Conclusion: For LVO stroke patients with high BP variability after EVT, worse functional outcome may be exacerbated by impaired autoregulation. These results suggest that autoregulatory status should be considered in the management of BP after EVT.

Background/Aims: Blood pressure variability (BPV) is a novel cardiovascular risk factor for the population undergoing hemodialysis (HD). Methods: We conducted a retrospective cohort study of 526 HD patients. Four short-term peridialysis BPV metrics were analyzed: systolic blood pressure (SBP) change, SBP coefficient of variation (CV), SBP intradialytic average real variability (ARV), and absolute SBP residual. Multi variate analysis with Cox regression models were used to account for the potential confounders. Results: Short-term BPV is found to be affected by age, pre-dialysis SBP, antihypertensive drugs, dialysis time, and vascular access. Calcium-channel blockers (CCBs) were found to be associated with lower BPV than those on non-CCB therapy or no antihypertensive drugs. Patients dialyzed in the morning had a greater absolute SBP change than those dialyzed in the afternoon or evening. Patients using fistulas had a lower BPV than catheters. Higher BPV metrics including SBP CV (unadjusted hazard ratio [HR]: 1.37, 95% confidence interval [CI] 1.14-1.66, p=0.001), SBP intradialytic ARV (unadjusted HR: 1.46, 95% CI: 1.20-1.77, p< 0.001), and SBP residual (unadjusted HR: 1.47, 95% CI: 1.21-1.79, p< 0.001) were associated with a greater risk of cardiovascular events. After complete multivariate adjustment for other potential confounders, the HR remained statistically significant for SBP intradialytic ARV (HR 1.31, 95% CI: 1.04-1.66, p=0.024). Conclusion: Peridialytic BPV may be a potential target for improved blood pressure (BP) management in HD patients. Each short-term BPV metric has different advantages and disadvantages and should be applied according to the clinical context and purpose.

Background. In recent years the deterioration of the demographic situation has been noted in most countries of the world that is due to the steady increase in population of arterial hypertension and the aging of the population. According to the statistical forecast of the UN by 2025, the number of people over 60 will exceed 1 billion which is 15% of the entire global population. In Ukraine, according to epidemiological studies, the prevalence of hypertension among circulatory system diseases in adults (18 years and older) is 46.8% and almost half of patients with circulatory system diseases have elevated blood pressure. In patients aged 65 years and older, the prevalence of hypertension varies in the range of 53-72%. It has long been proven that the risk of cardiovascular and cerebrovascular complications in hypertensive patients depends not only on the absolute blood pressure level but also on fluctuations in blood pressure over different periods that is blood pressure variability. Blood pressure is not a static parameter but rather undergoes continuous fluctuations over time due to the interaction between environmental factors and behaviour on the one hand and the internal regulatory mechanisms of the cardiovascular system on the other hand. Elevated blood pressure may indicate cardiovascular dysregulation and itself may be a cardiovascular risk factor associated with increased all-cause mortality and cardiovascular mortality, stroke, coronary artery disease, heart failure, end-stage renal disease and incidence of dementia. Aim. The study aimed to improve the system of prevention and diagnosis of elderly and senior hypertensive patients at the ambulatory-polyclinic stage due to the study of the contribution of blood pressure variability. Materials and methods. The group of examinees was formed taking into account 27 elderly and senile hypertensive patients including those combined with coronary artery disease. For this purpose, ambulatory blood pressure monitoring was used. Results. Systolic blood pressure variability (SD) in hypertensive patients was higher than in the control group (p&lt;0.001). So, during the study, SD was 17.9±7.1 mm Hg. while in the control group 12.1±2.6 mm Hg. The frequency of high blood pressure variability detection in elderly and senile hypertensive patients was 51.9% (n=14). High blood pressure variability compared to low blood pressure variability and control was associated with a more pronounced systolic blood pressure variability (during the active monitoring period), and it was equalled 23.7±5.2 mm Hg compared to 14.8±6.5 mm Hg (p&lt;0.001) and 12.1±2.6 mm Hg. (p&lt;0.001). In elderly and senile hypertensive patients with high and low blood pressure variability, the non-dipper group prevailed over the dipper group in the structure of daily blood pressure rhythm (71.4% vs. 28.6% and 84.6% vs. 15.4% respectively). According to the ambulatory blood pressure monitoring data high blood pressure variability group compared to low blood pressure variability and controls was characterised by higher average values of the number of blood pressure indicators. In the group of high blood pressure variability patients, the average daily systolic blood pressure exceeded the control value by 10% (р&lt;0.05). The daily index of systolic blood pressure in the group of high blood pressure variability patients was 111% higher than in patients with low blood pressure variability (p&lt;0.05). The daily index of diastolic blood pressure in the group of high blood pressure variability patients was 140% higher than in patients with low blood pressure variability (p&lt;0.05). The daily index of average blood pressure in the group of high blood pressure variability patients was 191% higher than in patients with low blood pressure variability (p&lt;0.01). Conclusions. 1. High blood pressure variability has occurred in 16 out of 27 (51.9%) hypertensive elderly and senile patients. 2. The non-dipper group has predominated in the structure of blood pressure diurnal rhythm in elderly and senile hypertensive patients with high and low blood pressure variability patients. _________________________________________________________________________________________ Keywords: arterial hypertension; essential hypertension; blood pressure variability; high blood pressure variability; low blood pressure variability; elderly and senile hypertensive patients

Background: Both increased blood pressure (BP) variability and impaired autoregulation have been linked to worse outcome after endovascular thrombectomy (EVT). This study examined the combined effect of these variables on the risk of poor outcome in patients with large-vessel occlusion (LVO) stroke. Methods: Autoregulation was continuously measured for up to 24 hours after EVT and quantified as a moving correlation coefficient between arterial BP and the near-infrared spectroscopy-derived cerebral oxygen saturation. Systolic BP variability was assessed using the standard deviation of the mean. Values were averaged for the entire recording period and dichotomized at the lowest tertile for both variables. Functional outcome was assessed using the modified Rankin scale (mRS) at 90 days and dichotomized into good (mRS 0-2) and poor outcome (mRS 3-6). Results: We included 195 patients (mean age 70 + 16, 45% female, mean NIHSS 14, mean monitoring time 15 + 7 hours). After adjusting for age, NIHSS, ASPECTS, and TICI score, patients with low BP variability and intact autoregulation were significantly more likely to achieve a good outcome than those with high BP variability and impaired autoregulation (OR 3.7, 95% CI 1.2-12.1, p=0.028, Figure 1A). We found an interaction between BP variability and autoregulation (p=0.067). Patients with high BP variability showed a gradual decrease in the probability of a good outcome with worsening autoregulation. However, for patients with low BPV, autoregulation had minimal impact. (Figure 1B). No significant correlation was seen between autoregulatory function and BP variability (r=0.07, p=0.33). Conclusions: For LVO stroke patients with high BP variability after EVT, worse 90-day functional outcome may be exacerbated by impaired autoregulation. These results suggest that autoregulatory status should be considered in the management of BP after EVT to identify high-risk patients and develop individualized treatment strategies.

Blood pressure (BP) variability (BPV) is a novel risk factor for the development of atherosclerotic diseases. High BPV has recently been shown to predict all-cause and cardiovascular mortality in patients with lacunar infarct. Whether BPV has prognostic implications in patients with ischemic stroke subtypes, other than those due to small-vessel occlusion, remains uncertain. We prospectively followed up the clinical outcome of 632 consecutive ischemic stroke patients without atrial fibrillation. The average BP and BPV, as determined by the coefficient of variation of the systolic and diastolic BP, were recorded during a mean 12 ± 6 outpatient clinic visits. The average age of the population was 71 ± 11 years. After a mean of 76 ± 18 months of follow-up, 161 patients died (26%); 35% (n = 56 of 161) of these deaths were due to cardiovascular causes. Sixteen percent and 5% developed recurrent stroke and acute coronary syndrome (ACS), respectively. After adjusting for mean systolic BP and confounding variables, patients with high systolic BPV were at significantly greater risk of cardiovascular mortality (hazards ratio (HR) = 2.36; 95% confidence interval (CI) = 1.02-5.49; P < 0.05). High systolic BPV also predicted all-cause mortality after adjusting for mean systolic BP (HR = 1.79; 95% CI = 1.16-2.75; P < 0.05). There was no association between systolic BPV and nonfatal recurrent stroke or nonfatal ACS. Raised diastolic BPV did not predict recurrent nonfatal stroke, nonfatal ACS, or mortality. Visit-to-visit systolic BPV predicts long-term all-cause and cardiovascular mortality in patients with ischemic stroke without atrial fibrillation, independent of other conventional risk factors, including average BP control.

Although high visit-to-visit blood pressure variability (BPV) is an independent risk factor for cardiovascular events, the frequency of high BPV is unknown. We conducted this study to define the frequency of high BPV in primary care patients, clinical correlates, and association with antihypertensive therapies. Retrospective cohort study using electronic medical record data (with previously validated case definitions based on billing codes, free text analysis of progress notes, and prescribing data) from the Canadian Primary Care Sentinel Surveillance Network of 221,803 adults with multiple clinic visits over a 2-year period. We a priori defined a standard deviation>13.0 mm Hg in visit-to-visit systolic blood pressure (SBP) as "high BPV" based on prior literature. Overall, 85,455 (38.5%) patients had hypertension (mean 6.56 visits with SBP measurement, mean SBP 134.4 with Standard Deviation [SD] 11.3, 33.2% exhibited high BPV) and 136,348 did not (mean 3.96 visits with SBP measurement, mean SBP 120.9 with SD 8.2, 16.5% had high BPV). BPV increased with age regardless of whether individuals had hypertension or not; at all ages BPV varied across antihypertensive treatment regimens and was greater in those receiving renin angiotensin blockers or beta-blockers (p<0.001). High BPV was more frequent in patients with diabetes, chronic kidney disease, dementia, depression, chronic obstructive pulmonary disease, or Parkinson's disease. High visit-to-visit BPV is present in one sixth of non-hypertensive adults and one third of hypertensive individuals and is more common in those with comorbidities. The frequency of high BPV varies across antihypertensive treatment regimens.

Ambulatory Blood Pressure in Chronic Kidney Disease: Ready for Prime Time?