Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Women's Health, Saint Louis University School of Medicine, Saint Louis, MO.
Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Women's Health, Saint Louis University School of Medicine, Saint Louis, MO.
Am J Obstet Gynecol MFM. 2021 Nov;3(6):100455. doi: 10.1016/j.ajogmf.2021.100455. Epub 2021 Aug 8.
Pulse pressure is a proposed means of tailoring antihypertensive therapy for treatment of acute-onset, severe hypertension in pregnancy.
This study aimed to determine whether pulse pressure predicts response to the various first-line antihypertensive medications.
This is a retrospective cohort study from a single academic tertiary care center between 2015 and 2018. Patients were screened for inclusion if they had severe hypertension (defined as systolic blood pressure of ≥160 mm Hg or diastolic blood pressure of ≥110 mm Hg) lasting at least 15 minutes and were initially treated with intravenous labetalol, intravenous hydralazine, or immediate-release oral nifedipine. If a patient had multiple episodes of acute treatment during the pregnancy, only one episode was included in the analysis. The primary outcome was time to resolution (in minutes) of severe hypertension. To adjust for factors that may have affected time to resolution, we first compared baseline characteristics on the basis of the antihypertensive agent received. We then assessed the association between baseline characteristics and resolution of severe hypertension within 60 minutes of treatment. Regression analysis incorporated pulse pressure and antihypertensive agents into a model to predict resolution within 60 minutes of onset of severe hypertension.
A total of 479 women hospitalized with severe maternal hypertension met the inclusion criteria. Hydralazine was the initial antihypertensive agent administered to 113 women, whereas 233 received labetalol, and 133 received nifedipine. Those who initially received nifedipine had a shorter mean time to resolution of severe hypertension (32.6 minutes vs 46.3 for hydralazine and 50.3 for labetalol; P<.01) and were more likely to have resolution of severe hypertension within 60 minutes (91.0% vs 77.9% for hydralazine and 76.8% for labetalol; P<.01). Nifedipine also resulted in a lower mean posttreatment blood pressure. Regression analysis revealed that a lack of resolution of severe hypertension within 60 minutes was independently associated with 2 measures of hypertension severity (mean arterial pressure of ≥125 mm Hg and the need for ≥2 doses of medication) and pulse pressure of >75 mm Hg at the time of treatment, initial treatment with labetalol, and gestational age of <37 weeks at the time of the hypertensive event (or at delivery if treatment was after delivery). The model's bias-corrected bootstrapped area under the receiver operating characteristic curve was 0.85 (95% confidence interval, 0.79-0.88). Interaction terms between pulse pressure and each antihypertensive agent were not significant and therefore not incorporated into the final model.
Pulse pressure did not predict response to the various first-line antihypertensive agents. Initial treatment with oral nifedipine was associated with a higher likelihood of resolution of severe hypertension within 60 minutes of treatment than with intravenous labetalol.
脉压是一种用于调整降压治疗以治疗妊娠急性发作性重度高血压的方法。
本研究旨在确定脉压是否可以预测各种一线降压药物的反应。
这是一项回顾性队列研究，来自 2015 年至 2018 年的一家学术性三级保健中心。如果患者有持续至少 15 分钟的重度高血压（定义为收缩压≥160mmHg 或舒张压≥110mmHg），并最初接受静脉拉贝洛尔、静脉肼屈嗪或立即释放硝苯地平治疗，则对其进行筛选以纳入研究。如果患者在怀孕期间有多次急性治疗发作，只分析一次发作。主要结局是重度高血压缓解所需的时间（以分钟计）。为了调整可能影响缓解时间的因素，我们首先根据所接受的降压药物比较了基线特征。然后评估了基线特征与治疗后 60 分钟内重度高血压缓解之间的关联。回归分析将脉压和降压药物纳入模型，以预测重度高血压发作后 60 分钟内的缓解。
共有 479 名因重度产妇高血压住院的女性符合纳入标准。113 名女性最初接受肼屈嗪作为降压药物，而 233 名女性接受拉贝洛尔，133 名女性接受硝苯地平。最初接受硝苯地平的患者重度高血压缓解的平均时间更短（32.6 分钟，而肼屈嗪为 46.3 分钟，拉贝洛尔为 50.3 分钟；P<.01），在 60 分钟内缓解重度高血压的可能性更高（91.0%，而肼屈嗪为 77.9%，拉贝洛尔为 76.8%；P<.01）。硝苯地平还导致平均治疗后血压降低。回归分析显示，60 分钟内未缓解重度高血压与 2 项高血压严重程度指标（平均动脉压≥125mmHg 和需要≥2 剂药物）和治疗时脉压>75mmHg、初始使用拉贝洛尔以及高血压事件时的胎龄<37 周（如果分娩后进行治疗，则为分娩时）独立相关。模型校正后的偏倚自举接受者操作特征曲线下面积为 0.85（95%置信区间，0.79-0.88）。脉压与每种降压药物之间的交互项不显著，因此未纳入最终模型。
脉压不能预测各种一线降压药物的反应。与静脉拉贝洛尔相比，初始口服硝苯地平治疗在 60 分钟内缓解重度高血压的可能性更高。
