Admission Diastolic Blood Pressure Research Articles

Association between ASPECTS region of infarction and clinical outcome in non-acute large vessel occlusion ischaemic stroke after endovascular recanalisation

PurposeThis study retrospectively investigated whether infarction in specific Alberta Stroke Program Early CT Score (ASPECTS) regions is associated with clinical outcome in patients with symptomatic non-acute internal carotid or middle...

Nomogram to predict ventilator-associated pneumonia in large vessel occlusion stroke after endovascular treatment: a retrospective study.

Ventilator-Associated Pneumonia (VAP) severely impacts stroke patients' prognosis after endovascular treatment. Hence, this study created a nomogram to predict the occurrence of VAP after endovascular treatment. The individuals with acute ischemic stroke and large vessel occlusion (AIS-LVO) who received mechanical ventilation and endovascular therapy between July 2020 and August 2023 were included in this retrospective study. The predictive model and nomogram were generated by performing feature selection optimization using the LASSO regression model and multifactor logistic regression analysis and assessed the evaluation, verification and clinical application. A total of 184 individuals (average age 61.85 ± 13.25 years, 73.37% male) were enrolled, and the rate of VAP occurrence was found to be 57.07%. Factors such as the Glasgow Coma Scale (GCS) score, duration of stay in the Intensive Care Unit (ICU), dysphagia, Fazekas scale 2 and admission diastolic blood pressure were found to be associated with the occurrence of VAP in the nomogram that demonstrating a strong discriminatory power with AUC of 0.862 (95% CI, 0.810-0.914), and a favorable clinical net benefit. This nomogram, comprising GCS score, ICU duration, dysphagia, Fazekas scale 2 and admission diastolic blood pressure, can aid clinicians in predicting the identification of high-risk patients for VAP following endovascular treatment in large vessel occlusion stroke.

The role of arginine vasopressin in the pathophysiology of microvascular dysfunction after ST-elevation myocardial infarction

Abstract Background Coronary microvascular dysfunction (CMD) after ST-elevation myocardial infarction (STEMI), in part due to impaired vasomotor tone, predicts heart failure and mortality at one year. Arginine vasopressin (AVP) may be implicated in CMD as it is released during MI and has known vasoconstrictor effects, but data in humans are lacking. We examined the role of copeptin, a stable plasma surrogate marker of AVP, in humans with STEMI. Methods We included three cohorts. The first cohort prospectively recruited patients presenting with STEMI eligible for primary percutaneous coronary intervention (PPCI) (n= 55). In this cohort, the index of microcirculatory resistance (IMR) and coronary flow reserve (CFR) were measured in the culprit artery at the end of the procedure. The second cohort included 45 patients from a sub-study of the CAPRI trial (Evaluating the effectiveness of intravenous Ciclosporin on reducing reperfusion injury in pAtients undergoing PRImary PCI; NCT02390674). In this cohort, patients underwent cardiac magnetic resonance (CMR) imaging at one and 12 weeks post-MI, allowing precise measurement of infarct size and microvascular obstruction (MVO), the imaging hallmark of CMD. Both cohorts had serum copeptin measured at four time points. The 3rd cohort included two patients undergoing trans-coronary alcohol ablation of septal hypertrophy (TASH). Serial copeptin measurements were performed in this cohort to assess copeptin release in an induced ischaemia setting. Results One hundred patients were included from both STEMI cohorts. Copeptin levels paralleled AVP plasma levels closely, with mean levels falling in the 24 hours after reperfusion from 92.5 pmol/L to 6.4 pmol/L, and this was mirrored in the TASH patients. Copeptin release wasinversely linked to admission diastolic blood pressure (DBP) (Spearman’s rho r= -0.431, p=0.001), but did not correlate with systolic blood pressure. Copeptin levels at 24 hours were significantly associated with high IMR (r=0.372, p=0.011) and low CFR (r=-0.467, p=0.001). Patients with IMR >40 also had significantly higher mean copeptin concentration at 24 hours than those with lower IMR (19.1 vs 7.1pmol/L, p=0.019, Figure 1). Finally, patients with MVO on early CMR showed a trend towards higher mean copeptin concentration at baseline, although this was not statistically significant. Notably, copeptin levels were not associated with infarct size on either early or late CMR. Conclusions Copeptin, and therefore AVP, is released secondary to acute myocardial ischaemia, particularly in response to reduced coronary perfusion, as evidenced by the inverse correlation with DBP, and normalises by 24 hours. However, evidence of CMD was seen in patients with persistently elevated copeptin at 24 hours, suggesting AVP may contribute to microcirculatory dysfunction. AVP receptor antagonists may represent a novel therapeutic option in patients with STEMI and evidence of microvascular dysfunction.

Factors Predicting Transformation of Non-Severe Pre-Eclampsia into Pre-Eclampsia with Severe Features

Background: Pre-eclampsia (PE), a complex, multisystem, pregnancy-associated hypertensive disorder, typically developing after the 20th week of gestation, that complicates 2% - 8% of pregnancies, is a leading cause of neonatal and maternal mortality and morbidity. Aim of the Work: To identify different factors predicting transformation of non-severe pre-eclampsia in to pre-eclampsia with severe features. Patients and Methods: This prospective cohort study was conducted at tertiary care hospital at Ain Shams University hospitals from June 2021 till January 2022 and performed on total of 100 patients who diagnosed as non-severe pre-eclampsia after exclusion of severity features. Results: The current study revealed that transformation to severe pre-eclampsia occurred in 33% of the studied cases. Body mass index (BMI), past and family histories of preeclampsia statistically were significantly higher in cases transformed into preeclampsia with severe features. Admission blood pressure, albumin dipstick, Oligohydramnios and IUGR statistically were significantly higher in cases with transformation from non-severe pre-eclampsia into pre-eclampsia with severe features. Platelet count statistically was significantly lower in cases with transformation from non-severe pre-eclampsia into pre-eclampsia with severe features Conclusion: Our study results identified the most important clinical risk factors for transformation to severe features of pre-eclampsia from non-severe features and provided new information on the level of risk associated with specific combinations of risk factors (BMI ≥ 35.4, admission systolic blood pressure, admission diastolic blood pressure, albumin dipstick 4+ and platelets count) with low significant diagnostic performance in predicting transformation from non-severe pre-eclampsia into pre-eclampsia with severe features.

PS-C06-4: RELATIONSHIP BETWEEN URINARY MICROALBUMIN AND LIPID ACCUMULATION PRODUCT AND VISCERAL ADIPOSITY INDEX IN PATIENTS WITH ESSENTIAL HYPERTENSION

Objective: To explore the relationship between urinary microalbumin and lipid accumulation product and visceral adiposity index in patients with essential hypertension. Design and method: A total of 463 essential hypertension patients admitted to the Department of Hypertension of the First Affiliated Hospital of Xinjiang Medical University from April 2020 to October 2021 were selected. Patients were grouped according to 24-hours urinary microalbumin and divided into normal 24-hours urinary microalbumin group and elevated 24-hours urinary microalbumin group to compare the clinical data of the two groups and analyze the risk factors of elevated urinary microalbumin. Results: The 24-hours urinary microalbumin was positively associated with lipid accumulation product and visceral adiposity index in patients with essential hypertension(all P < 0.01). The risk of elevated 24-hours urinary microalbumin may increase with increasing lipid accumulation product,visceral adiposity index. After adjusting for age,sex,admission systolic blood pressure,admission diastolic blood pressure,body mass index,triglycerides,high density lipoprotein cholesterol,serum creatinine,the OR (95%CI) of lipid accumulation product in the fourth quantile group was 4.770 (1.680∼13.545) compared with the first quantile of lipid accumulation product. The OR (95%CI) values of visceral adiposity index in the second,third and fourth quartile groups were 3.364 (1.330∼8.512),3.440 (1.249∼9.472),and 5.213 (1.556∼17.461),compared with the first quartile group of visceral adiposity index. Analysis of the receiver operating characteristic curve suggested that the risk of elevated urinary microalbumin increases when the lipid accumulation product is greater than 32.236 and the visceral adiposity index is greater than 2.031. Conclusion: When the lipid accumulation product and visceral adiposity index increase in patients with essential hypertension, they may lead to an increased risk of increased urinary microalbumin.

The diastolic blood pressure U-curve

Abstract Introduction It is known that low diastolic blood pressure (DBP) at admission is associated with short-term cardiovascular events after acute coronary syndrome (ACS). However, there is a lack of further investigation into the nonlinear relationship between admission diastolic blood pressure (DBP) and adverse outcomes of ACS patients. Objective To investigate the relationship between admission diastolic blood pressure and subsequent cardiovascular mortality in patients with acute coronary syndrome. Methods Retrospective study of patients with ACS periodically included in our center registry between October/2012 and September/2018. Patients with class killip 4 at admission or that needed ionotropic support during hospitalization were excluded. The association between admission DBP and cardiovascular mortality during the follow-up period among this population was analyzed using multivariate COX regression model. Results were presented according to DBP quartiles: Q1, less than 70 mm Hg; Q2, from 71 to 80 mm Hg; Q3, from 81 to 90 mm Hg; Q4, above 90 mmHg. Results A total of 548 patients were included in this cohort study. Mean patient age was 65.9±13.1 years and 75.2% were men. A nonlinear relation was observed between DBP at admission and cardiovascular mortality over the follow-up. During a median follow-up of 42 months (IQR: 27–59), 47 patients (8.6%) died from cardiovascular causes. After adjusting for potential confounders (age and diabetes mellitus), patients in Q3 had the lowest risk for cardiovascular death by Cox proportional hazard model (HR 0.44; 95% CI: 0.16–1.00). Meanwhile, compared with Q1, Q3 patients had significantly lower risk for cardiovascular death (HR 0.35, 95% CI: 0.13–0.92). Conclusion Among patients admitted for ACS, there is a U curve relationship between admission DBP and risk for cardiovascular death. These results could be explained by a reduction in diastolic coronary blood flow which influences myocardial oxygen supply relative to the necessary demand in an ACS. Funding Acknowledgement Type of funding sources: None.

OR37. Factors associated with in-hospital mortality in patients hospitalized with acute coronary syndrome

Abstract Background and Aims Acute coronary syndrome (ACS) remains a source of high mortality worldwide, therefore it is important to determine factors associated with worse outcomes to better develop strategies to reduce the burden of disease. This paper aims to describe the characteristics of patients admitted with ACS to Kediri General Hospital and factors associated with in-hospital mortality. Methods and Result In this study, 117 patients admitted with ACS to Kediri General Hospital between January and June 2020 were included. Data were collected retrospectively from medical records and analysed using SPSS software v25. The median age was 60 (36-93) years old, 64 (54,7%) were male. They were presented either with STE-ACS (41%) or NSTE-ACS (59%). During hospitalization, 18 (15,4%) died. The bivariate analysis showed the patients who died were predominantly female (22,6% vs 9,4%, p = 0.048); had higher prevalence of Killip IV (38,9%, p = 0,003); higher prevalence of clinical signs of heart failure (23,7% vs 6,9%, p = 0,012); lower admission systolic blood pressure (117 ± 26,0 vs 137 ± 37,0, p = 0,036); lower admission diastolic blood pressure (70,6 ± 20,6 vs 81,5 ± 20,5, p = 0,04); and higher heart rate (104 ± 24 vs 91 ± 22, p = 0,026). From multivariable analysis, variables significantly associated with in-hospital mortality were decreased consciousness (OR 11, 95% CI 1.327-92.4, p = 0.026) and Killip class IV (OR 9.558, 95% CI 2.016-45.317). Conclusion Decreased consciousness and Killip class IV were significant independent predictors of in-hospital mortality in ACS.

J-shaped relationship between admission diastolic blood pressure and 2-year cardiovascular mortality in elderly patients with acute coronary syndrome

Abstract Objective To investigate the relationship between admission diastolic blood pressure (DBP) and subsequent cardiovascular and all-cause mortality in elderly patients with acute coronary syndrome (ACS). Methods This is a retrospective observational study. Consecutive patients ≥65 years of age admitted for ACS at a 2,300-bed tertiary hospital from December 2012 to July 2019 were included. The association between admission DBP and cardiovascular and all-cause mortality during hospitalization and over the follow-up period among this population were analyzed using multivariate COX regression model. Results were presented according to DBP quartiles: Q1, less than 67 mm Hg; Q2, from 67 to 72 mm Hg; Q3, from 73 to 80 mm Hg; and Q4, above 80 mm Hg. Results A total of 6 785 patients were included in this cohort study. Mean (SD) patient age was 74.0 (6.5) years, and 47.6% were women. Mean (SD) follow-up time was 2.54 (1.82) years. A non-linear relation was observed between DBP at admission and cardiovascular and all-cause mortality during hospitalization and over the follow-up period using restricted cubic splines. After adjustment for potential confounders, patients in Q3 or Q2 had lower risk for 2-year cardiovascular death by Cox proportional hazard model compared with patients in Q4 (hazard ratio [HR] 0.66; 95% confidence interval [CI], 0.48–0.90, P=0.010, for Q3 vs Q4; and HR 0.72; 95% CI, 0.53–0.99, P=0.041, for Q2vs Q4), while patients in Q1 had similar risk for cardiovascular death with that of patients in Q4. Meanwhile, when compared with patients in Q1, patients in Q3 had lower risk for 2-year cardiovascular death (HR, 0.72; 95% CI, 0.53–0.97, P=0.033). However, lower or higher admission DBP was not an independent predictor of 2-year all-cause mortality in this population. Conclusion Among patients aged ≥65 years admitted for ACS, there is a J-curve relationship between supine admission DBP and risk for 2-year cardiovascular death, with a nadir at 73–80 mm Hg. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): the Beijing Municipal Administration of Hospitals Clinical Medicine Development of Special Funding Support Study population and selectionAdjusted multivariate COX regression

Factors associated with the presence of cerebral microbleeds and its influence on outcomes of stroke not treated with alteplase

ObjectivesCerebral microbleeds (CMB) are associated with increased risk of hemorrhagic transformation (HT) of ischemic stroke with alteplase. Whether the presence of CMB influences the risk of HT and discharge outcomes of stroke patients not receiving alteplase is unclear. We evaluated the factors associated with the presence of CMB, and if the rates of HT and discharge outcomes were modified by the presence of CMB among stroke patients not treated with alteplase. MethodsIschemic stroke patients who had MRI and did not receive alteplase were included in the study. CMB, HT and white matter hyperintensity (WMH) were evaluated using Microbleed Anatomical Rating Scale, Heidelberg bleeding classification, and Fazekas scales, respectively. Multivariate regression analysis was performed to evaluate factors associated with the presence of CMB. ResultsAmong 196 patients in the study, 58 (30%) patients had CMB. Nine patients had ≥ 10 CMBs. Median National Institutes of Health stroke scale score was 4. In multivariate analysis, age (OR=1.07;95%CI=1.01–1.12), history of stroke (OR=3.10;95%CI=1.08–8.92), congestive heart failure (OR=7.26;95%CI=1.58–33.42), admission diastolic blood pressure (OR=1.03;95%CI=1.003–1.06) and severe WMH defined as Fazekas score 4–6 (OR=4.69;95%CI=1.80–12.23) were significantly associated with the presence of CMB. There was no difference in HT (10% vs 12%, p = 0.80) or discharge outcomes (modified Rankin Scale 0–2: 53% vs 57%, p = 0.62) of patients with CMB compared to those without CMB. ConclusionCMB are associated with severe WMH and higher diastolic blood pressure. CMB are not associated with the HT occurrence or discharge outcome of mild ischemic stroke in the absence of alteplase.

Check the diastolic blood pressure twice in aortic dissection as it is associated with prognosis.

Objective:In this study we aimed to determine the prediction level of admission diastolic blood pressure (DBP) on the prognosis and mortality in aortic dissection patients over 65 years old and under 65 years old.Methods:We included 72 patients in this retrospective study and study groups were divided into two groups according to 65 age. Demographic data, dissection type (Stanford A-B), DBP, systolic blood pressure (SBP), mean arteriel pressure (MAP), heart rate (/min) main complaints, preoperative length of stay, hospitalisation clinic (clinic/intensive care unit), length of hospitaliisation, complications during hospitalisation (renal failure etc..) and the outcome (death/dischargement) results were noted. Preoperative lenth of stay, hospitalisation length, outcome and complications were compared between groups according to SBP, DBP, MAP and heart rate.Results:Mean blood pressure values of the Stanford type B patients over 65 years old were higher than the other group (p<0.05). Fifty percent of patients under 65 years old were discharged but this ratio was 26.9% in the elder group. DBP was positively correlated with preoperative length of stay and hospitalisation length and negatively correlated with mortality. DBP under 65 mmHg was significantly related with high mortality (p<0.05). When the age and presentation time heart rate is added to each other, the values over 142 were significantly related with high mortality (p<0.05).Conclusions:The presentation time vital signs especially the DBP may be helpful for emergency clinicians to predict the prognosis and outcome in aortic dissection patients which has high mortality ratio in patients over 65 years of age.

Normal-appearing white matter microstructural injury is associated with white matter hyperintensity burden in acute ischemic stroke.

White matter hyperintensity of presumed vascular origin is a risk factor for poor stroke outcomes. In patients with acute ischemic stroke, however, the invivo mechanisms of white matter microstructural injury are less clear. To characterize the directional diffusivity components in normal-appearing white matter and white matter hyperintensity in acute ischemic stroke patients. A retrospective analysis was performed on a cohort of patients with acute ischemic stroke and brain magnetic resonance imaging with diffusion tensor imaging sequences acquired within 48 h of admission. White matter hyperintensity volume was measured in a semi-automated manner. Median fractional anisotropy, mean diffusivity, radial diffusivity, and axial diffusivity values were calculated within normal-appearing white matter and white matter hyperintensity in the hemisphere contralateral to the acute infarct. Linear regression analysis was performed to evaluate predictors of white matter hyperintensity volume and normal-appearing white matter diffusivity metrics. In 319 patients, mean age was 64.9 ± 15.9 years. White matter hyperintensity volume was 6.33 cm3 (interquartile range 3.0-12.6 cm3). Axial and radial diffusivity were significantly increased in white matter hyperintensity compared to normal-appearing white matter. In multivariable linear regression, age (β = 0.20, P = 0.003) and normal-appearing white matter axial diffusivity (β = 37.9, P < 0.001) were independently associated with white matter hyperintensity volume. Subsequent analysis demonstrated that increasing age (β = 0.004, P < 0.001) and admission diastolic blood pressure (β = 0.001, P = 0.02) were independent predictors of normal-appearing white matter axial diffusivity in multivariable linear regression. Normal-appearing white matter axial diffusivity increases with age and is an independent predictor of white matter hyperintensity volume in acute ischemic stroke.

Value of N-terminal pro-brain natriuretic peptide and aortic diameter in predicting in-hospital mortality in acute aortic dissection

ObjectiveTo determine the value of N-terminal pro-brain natriuretic peptide (NT-proBNP) and aortic diameter in predicting in-hospital mortality in acute aortic dissection (AD). MethodsA single-center prospective study was designed in the setting of University hospital in China. 122 patients with acute AD were enrolled. Admission plasma NT-proBNP levels and aortic diameter were measured. ResultsPlasma NT-proBNP concentrations (P < 0.001), aortic diameter (P = 0.002), and admission systolic blood pressure (SBP) (P = 0.011) were significantly increased in patients who died compared to those who survived during hospitalization. Furthermore, aortic diameter had positive correlations with NT-proBNP levels (r = 0.270, P = 0.003) and admission diastolic blood pressure (DBP) (r = 0.202, P = 0.025), respectively. Multiple logistic regression analysis demonstrated that NT-proBNP ≥569.75 pg/ml and aortic diameter ≥40 mm were strongly associated with in-hospital mortality. The odds ratio (OR) and 95% confidence interval (CI) were 3.246, 1.212–8.693 (P = 0.019); and 2.917, 1.102–7.722 (P = 0.031), respectively. Moreover, when NT-proBNP ≥1325.6 pg/ml, the sensitivity and specificity of NT-proBNP in predicting in-hospital mortality risk were 55.2% and 95.7% (95% CI, 0.707–0.891; P < 0.001), respectively. In addition, when aortic diameter ≥47 mm, the sensitivity and specificity were 58.6% and 88.2% (95% CI, 0.607–0.841; P < 0.001), respectively. ConclusionsNT-proBNP ≥569.75 pg/ml and aortic diameter ≥40 mm were important risk factors and independently associated with acute AD in-hospital mortality. NT-proBNP ≥1325.6 pg/ml or aortic diameter ≥47 mm showed higher specificity in predicting in-hospital mortality. Using NT-proBNP and aortic diameter together showed better performance in predicting in-hospital mortality with higher sensitivity.

Abstract TP15: Systolic Blood Pressure on Initial Presentation: A Predictor of Infarct Size in Large Vessel Anterior Circulation Stroke Treated With Endovascular Therapy

Background: Endovascular treatment (EVT) of large vessel anterior circulation stroke has become standard of care. Emerging clinical trials have shown effectiveness of EVT for anterior circulation strokes beyond 6 hours after stroke onset. In addition to imaging criteria, it is important to understand clinical and demographic predictors of poor outcomes in this subgroup. Methods: A hospital based stroke registry was used for retrospective analysis of 225 consecutive cases of large vessel anterior circulation strokes. Poor outcome was defined as &gt;1/3 middle cerebral artery territory infarct (MCAI) on MRI diffusion weighted imaging or on CT scan performed approximately 24 hours from treatment. Multivariate logistic regression model was used to identify demographic and clinical predictors of poor outcome. IBM - SPSS version 24 was used for data analysis. Results: In the study cohort, 31.25% patients had &lt;1/3 MCAI. Group of patients with &gt;1/3 MCAI had higher admission NIHSS (National Institute of Health Stroke Scale) (19.37 Vs 15.52, p&lt;0.001) and admission systolic blood pressure (SBP) (153.28 Vs.138.54, p&lt;0.001) compared to &lt;1/3 MCAI group. There was no statistically significant difference noted in time from symptom onset to re-canalization (335.11 Vs 306.04, p=0.24), admission diastolic blood pressure (DBP) (80.19 Vs 80.81, p=0.83) SBP at 24 hour (132.00 Vs.132.61, p=0.84), and DBP at 24 hours 66.97 Vs 64.71, p=0.28). Higher admission SBP [Odds ratio (OR) 1.028; 95% CI (Confidence Interval) 1.002- 1.056, p=0.007) and NIHSS [OR 1.26; 95% CI 1.13 - 1.41, p&lt;0.001) independently predicted &gt;1/3 MCAI after controlling for clinical and demographic variables in multivariate logistic regression analysis. Conclusion: SBP on initial presentation predicted &gt;1/3 MCAI in large vessel anterior circulation strokes treated with EVT. This finding was in a setting of non-significant difference in DBP on initial presentation, SBP and DBP at 24 hours in &gt;1/3 MCAI versus &lt;1/3 MCAI groups. In addition to the understanding of tissue at risk based on imaging, optimal hemodynamic parameter goals need to be investigated in post thrombectomy care to minimize tissue injury.

Abstract TP186: High Hospital Mortality Among Non-black Stroke Patients with Metabolic Syndrome

Introduction: Limited information is available on race based stroke outcomes among patients with metabolic syndrome. Methods: We conducted a retrospective review of acute ischemic stroke patients between 2008 and 2015 who were admitted to stroke service at a comprehensive stroke center. Patients were categorized to have metabolic syndrome if they have three of the four criteria (history of hypertension or diabetes or triglycerides ≥ 150 mg/dl or high density lipoprotein (HDL) &lt; 50 mg/dl for women or &lt; 40 mg/dl for men). Patients with metabolic syndrome were grouped based on their race. Primary outcome was modified Rankin Scale score at discharge. Secondary outcomes measures were neurological worsening, hospital mortality, in-hospital complications, discharge stroke scale, and length of stay. Results: Total 659 patients were found to have metabolic syndrome. Among these patients, 206 (31%) were non-black and 453 (69%) were of black race. Compared to non-black patients with metabolic syndrome, black patients were more likely to be women (56% vs. 35%, p&lt;0.0001) and have a prior history of stroke (55% vs. 35%, p&lt;0.0001). Median admission diastolic blood pressure was higher among blacks compared to non-blacks (92 vs. 87mmHg, p = 0.0093). Higher proportion of black patients were on anti-platelets (67% vs. 56%, p = 0.01), statins (83% vs. 71%; p =0.001), and anti-hypertensive medications at home (90% vs. 81%, p = 0.001). Non-blacks had higher triglycerides (188 vs. 132 mg/dl, p&lt;0.0001) and lower HDL levels (36 vs. 44 mg/dl, p&lt; 0.0001). There was no difference in discharge modified Rankin Scale score among the groups. In-hospital myocardial infarction was significantly more frequent among non-blacks (9% vs. 4%, p = 0.03). In-hospital mortality was significantly higher in the non-black group (11% vs. 6%, p = 0.02). Conclusion: Non-black race was associated with higher in-hospital mortality among patients with metabolic syndrome admitted for stroke. Further exploration of higher mortality among this group of patients is warranted to improve stroke outcomes.

Low-Level Lead Exposure and Elevations in Blood Pressure during Pregnancy

BackgroundLead exposure is associated with elevated blood pressure during pregnancy; however, the magnitude of this relationship at low exposure levels is unclear.ObjectivesOur goal was to determine the association between low-level lead exposure and blood pressure during late pregnancy.MethodsWe collected admission and maximum (based on systolic) blood pressures during labor and delivery among 285 women in Baltimore, Maryland. We measured umbilical cord blood lead using inductively coupled plasma mass spectrometry. Multivariable models were adjusted for age, race, median household income, parity, smoking during pregnancy, prepregnancy body mass index, and anemia. These models were used to calculate benchmark dose values.ResultsGeometric mean cord blood lead was 0.66 μg/dL (95% confidence interval, 0.61–0.70). Comparing blood pressure measurements between those in the highest and those in the lowest quartile of lead exposure, we observed a 6.87-mmHg (1.51–12.21 mmHg) increase in admission systolic blood pressure and a 4.40-mmHg (0.21–8.59 mmHg) increase in admission diastolic blood pressure after adjustment for confounders. Corresponding values for maximum blood pressure increase were 7.72 (1.83–13.60) and 8.33 (1.14–15.53) mmHg. Benchmark dose lower limit values for a 1-SD increase in blood pressure were < 2 μg/dL blood lead for all blood pressure end points.ConclusionsA significant association between low-level lead exposures and elevations in maternal blood pressure during labor and delivery can be observed at umbilical blood lead levels < 2 μg/dL.

In-hospital worsening renal function is an independent predictor of one-year mortality in patients with acute myocardial infarction

BackgroundWe investigated the incidence, clinical predictors and prognostic value of worsening renal function (WRF) regarding 1-year mortality in patients with acute myocardial infarction (AMI). MethodsWe collected in-hospital data from 447 patients hospitalized for AMI in our institute within 12h of symptoms' onset. WRF was defined as a 25% or more decrease in estimated glomerural filtration rate during hospital stay. From blood samples obtained on admission and throughout hospitalization hemoglobin, white blood cell count, C-reactive protein, B-type natriuretic peptide, plasma glucose, troponin I and baseline and peak creatinine levels were measured. Ejection fraction was calculated on admission with 2D echocardiography. All patients underwent coronary arteriography and the revascularization status (complete or not) was also recorded. The end point was all-cause mortality after one-year of follow-up. ResultsWRF was detected in 63 pts (16.7%) and age, ejection fraction and white blood cell count emerged as the only independent predictors. The incidence of 1-year mortality was 10.7% (48 deaths). Patients with WRF exhibited higher 1-year mortality (37.5% vs. 6.3%, log rank p<0.001) and were characterized by more severe and less completely treated coronary artery disease, greater degree of myocardial necrosis and marked neurohormonal activation. By applying multivariate Cox regression analysis WRF, B-type natriuretic peptide, ejection fraction and admission diastolic blood pressure were identified as the only independent predictors of death. ConclusionsWRF is associated with adverse 1-year outcome in patients with AMI. Close monitoring of renal function in the acute phase of MI may substantially contribute to long-term risk stratification.

Anemia and hematoma volume in acute intracerebral hemorrhage

Anemia increases risk of bleeding complications in the critically ill. In primary intracerebral hemorrhage (ICH), the most fatal type of stroke, outcome is largely dependent on the volume of hemorrhage into the brain. We investigated the relationship between anemia and clinical course of acute ICH. Six hundred ninety-four consecutive subjects were identified from an ongoing single-center prospective cohort study of nontraumatic ICH during a 6-year period. Anemia was defined according to World Health Organization criteria. Study end points were ICH volume, as measured on the baseline computed tomography scan, and 30-day mortality. Anemia was present in 177 (25.8%) patients on admission. Patients with anemia were older (p = 0.005) and more likely to have coronary artery disease (p < 0.0001). In multivariable analysis, anemia (p = 0.009), lobar location of ICH (p < 0.001), white blood cell count (p < 0.001), and admission diastolic blood pressure (p < 0.001) were associated with larger ICH volume. Although after accounting for ICH volume, none of these variables was a significant predictor of 30-day mortality in multivariable analysis, the size of the marginal reduction in the odds ratio for anemia suggests that it may have a small effect on mortality through mechanisms in addition to ICH volume. Anemia is common in acute ICH and its presence at admission is an independent predictor of larger volume of ICH. Given the central role of ICH volume in outcome, clarification of the mechanisms underlying this relationship may offer novel therapeutic targets for reducing ICH morbidity and mortality.

Chloroquine-resistant Plasmodium falciparum cerebral malaria in a chloroquine-susceptible area.

Chloroquine-resistant Plasmodium falciparum is endemic in many areas. Saudi Arabia was considered to have chloroquine-susceptible P. falciparum. During the 1997-1998 season, an outbreak of malaria occurred in the southwestern region. Over a 4-month period, 32 cases (6.2%) of 520 malaria admissions met the World Health Organization criteria for cerebral malaria. The mean patient age was 28 years. Thirteen male and 19 female patients were admitted in coma. The mean duration of coma was 4.3 days; the case fatality rate was 41%. Compared with those who recovered, patients who died had a lower mean admission diastolic blood pressure and hemoglobin level, higher mean blood urea nitrogen and blood glucose levels, and thrombocytopenia. Logistic regression analysis identified treatment with quinine rather than chloroquine to be associated with survival. These findings show the potential of P. falciparum to emerge as chloroquine resistant in previously susceptible areas, resulting in significant morbidity and mortality in spite of sophisticated medical care.

Vascular Risk Factors Linked to Multiple Lacunar Infarcts

Background: The pathogenesis of lacunar infarcts is still incompletely established. Data from the literature suggest that vascular risk factors differ among patients with multiple (MLI) and single lacunar infarcts (SLI). We reexamined this hypothesis using stricter inclusion criteria and a less selected study population. Methods: We evaluated 136 patients consecutively admitted for first-ever minor stroke to a general hospital with the characteristics of a community hospital. Vascular risk factors were studied by univariate and multivariate statistical analyses among the following subgroups of patients, classified according to CT findings: (a) with lacunar infarct; (b) with nonlacunar infarct (NLI); (c) with SLI; (d) with MLI; (e) with single, either lacunar or nonlacunar, infarct. Results: No significant difference was observed between patients with lacunar infarcts and patients with NLI. Compared to patients with SLI or NLI, patients with MLI had significantly more often a family history of hypertension, cardiomegaly on the chest radiograph and CT leukoaraiosis as well as a higher systolic and diastolic blood pressure on admission. Logistic regression analysis selected CT leukoaraiosis, Rx cardiomegaly and admission diastolic blood pressure as independent, significant predictors of MLI. Conclusion: In patients with first-ever minor stroke, the risk factor profile differs according to the evidence of SLI or MLI on the CT scan. In terms of risk factors, patients with SLI seem more similar to those with NLI than those with MLI. Based on the predicting effect of variables linked with type and severity of arterial hypertension, the CT appearance of MLI might express a more univocal and specific cerebrovascular pathology (hypertensive arteriolosclerosis).