功能健康和脑白质高信号作为降压对老年患者认知功能和血管事件影响的调节因素：次级预防小皮质下中风试验参与者。
Functional health and white matter hyperintensities as effect modifiers of blood pressure-lowering on cognitive function and vascular events in older Secondary Prevention of Small Subcortical Strokes trial participants.
机构信息
Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California, USA.
Department of General Internal Medicine, Inselspital, Bern University Hospital.
出版信息
J Hypertens. 2020 Aug;38(8):1578-1585. doi: 10.1097/HJH.0000000000002440.
OBJECTIVE
To determine whether cerebral small vessel disease or disability modify the effect of SBP treatment on cognitive and vascular outcomes in older patients with recent lacunar stroke.
METHODS
Participants aged at least 65 years of the Secondary Prevention of Small Subcortical Strokes Trial were randomized to a higher (130-149 mmHg) or lower (<130 mmHg) SBP target. The primary outcome was change in cognitive function (Cognitive Abilities Screening Instrument); secondary outcomes were incident mild cognitive impairment, stroke, major vascular events (all-stroke, myocardial infarction), and all-cause death. Results were stratified by severity of white matter hyperintensities (WMH; none/mild, moderate, severe) on baseline MRI, and by disability (no vs. at least one limitation in activities of daily living).
RESULTS
One thousand, two hundred and sixty-three participants (mean age 73.8 ± 5.9 years, 40% women) were included. Participants with severe WMH or disability had worse cognitive function at baseline and after a mean follow-up of 3.9 years. No significant interactions existed between treatment group and effect modifiers (WMH, disability) for change in cognitive function (P for interaction 0.42 and 0.66, respectively). A lower SBP target appeared more beneficial among those with worse WMH burden for vascular outcomes (P for interaction = 0.01 for stroke and 0.03 for major vascular events).
CONCLUSION
There was no difference in the effect of lowering SBP to less than 130 mmHg on cognitive function by cerebral small vessel disease or disability among older adults with a history of lacunar stroke. Those with evidence of small vessel disease may derive greater benefit from lower SBP on prevention of subsequent vascular events.
TRIAL REGISTRATION
Clinicaltrials.gov Identifier: NCT00059306.
目的
确定脑小血管病或残疾是否会改变近期腔隙性卒中老年患者的 SBP 治疗对认知和血管结局的影响。
方法
次级预防小皮质下卒中试验的参与者年龄至少为 65 岁，随机分为较高（130-149mmHg）或较低（<130mmHg）的 SBP 目标。主要结局是认知功能变化（认知能力筛查工具）；次要结局是新发轻度认知障碍、卒中、主要血管事件（所有卒中、心肌梗死）和全因死亡。结果按基线 MRI 上的脑白质高信号（WMH）严重程度（无/轻度、中度、重度）和残疾（无 vs. 至少一项日常生活活动受限）分层。
结果
1263 名参与者（平均年龄 73.8±5.9 岁，40%为女性）入选。WMH 严重或残疾的参与者基线时认知功能较差，平均随访 3.9 年后认知功能下降。在认知功能变化方面，治疗组与效应修饰因子（WMH、残疾）之间没有显著的相互作用（交互作用的 P 值分别为 0.42 和 0.66）。对于血管结局，WMH 负荷较重的患者中，SBP 目标较低的获益更大（卒中的交互作用 P 值为 0.01，主要血管事件的交互作用 P 值为 0.03）。
结论
在有腔隙性卒中病史的老年患者中，降低 SBP 至<130mmHg 对认知功能的影响与脑小血管病或残疾无关。那些有小血管病证据的患者可能从较低的 SBP 中获得更大的预防后续血管事件的益处。
试验注册
Clinicaltrials.gov 标识符：NCT00059306。
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