Teng Rebecca S Y, Tan Benjamin Y Q, Miny Samuel, Syn Nicholas L, Ho Andrew F W, Ngiam Nicholas J H, Yeo Leonard L L, Choong Andrew M, Sharma Vijay K
Yong Loo Lin School of Medicine, National University of Singapore.
Division of Neurology, Department of Medicine, National University Health System.
J Stroke Cerebrovasc Dis. 2019 Apr;28(4):906-919. doi: 10.1016/j.jstrokecerebrovasdis.2018.12.008. Epub 2019 Jan 3.
Blood pressure (BP) is an important determinant of functional outcome in acute ischemic stroke (AIS) patients treated with intravenous tissue plasminogen activator (IV-tPA). Current guidelines recommend a BP target of 185/110 mmHg before IV-tPA bolus and maintaining it at less than 180/105 mmHg for the first 24 hours. However, the effect of blood pressure on various outcome measures after systemic thrombolysis remains unclear.
Following a systematic search of Medline and EMBASE, all observational studies reporting effect of pretreatment BP on 90-day functional outcome as measured by the modified Rankin Scale (mRS) and/ or incidence of symptomatic intracranial hemorrhage (sICH) in AIS patients receiving thrombolytic therapy were included.
Of 2181 studies screened, 26 studies, involving 38,937 subjects, met inclusion criteria. Higher prethrombolysis systolic BP was significantly-associated with poorer 90-day functional outcome (Mean difference 3.87 mmHg; 95% confidence interval [CI] 1.18-6.56) and increased incidence of sICH (Mean difference 5.31; 95% CI 2.22-8.40). When studies were stratified by different cut-offs for functional outcome (mRS 0-1 versus 0-2) and definitions of sICH used (Randomized controlled trials or SITS-MOST), there was no significant difference in mean difference between the subgroups.
Our data showed that higher prethrombolysis SBP was associated with poorer outcomes in thrombolysed acute ischemic stroke patients. This may suggest that more aggressive lowering of BP below the current recommendations prior to thrombolysis could be beneficial. The effect of early BP trends after tPA infusion could not be evaluated due to limited available data. Ongoing randomized clinical trials, like ENCHANTED, may provide further insights into the current guidelines and optimal BP levels.
血压（BP）是接受静脉注射组织纤溶酶原激活剂（IV-tPA）治疗的急性缺血性卒中（AIS）患者功能预后的重要决定因素。当前指南推荐在静脉推注IV-tPA前血压目标为185/110 mmHg，并在最初24小时内将其维持在180/105 mmHg以下。然而，全身溶栓后血压对各种预后指标的影响仍不明确。
在对Medline和EMBASE进行系统检索后，纳入所有报告溶栓前血压对接受溶栓治疗的AIS患者90天功能预后（采用改良Rankin量表[mRS]测量）和/或症状性颅内出血（sICH）发生率影响的观察性研究。
在筛选的2181项研究中，26项研究（涉及38937名受试者）符合纳入标准。溶栓前收缩压较高与90天功能预后较差（平均差异3.87 mmHg；95%置信区间[CI] 1.18 - 6.56）及sICH发生率增加（平均差异5.31；95% CI 2.22 - 8.40）显著相关。当根据功能预后的不同临界值（mRS 0 - 1与0 - 2）和所使用的sICH定义（随机对照试验或SITS - MOST）对研究进行分层时，亚组间平均差异无显著差异。
我们的数据表明，溶栓前较高的收缩压与溶栓治疗的急性缺血性卒中患者预后较差相关。这可能提示在溶栓前更积极地将血压降至当前推荐水平以下可能有益。由于可用数据有限，无法评估tPA输注后早期血压趋势的影响。正在进行的随机临床试验，如ENCHANTED，可能会为当前指南和最佳血压水平提供进一步的见解。
