Abramson Jessica R, Castello Juan Pablo, Keins Sophia, Kourkoulis Christina, Rodriguez-Torres Axana, Myserlis Evangelos Pavlos, Alabsi Haitham, Warren Andrew D, Henry Jonathan Q A, Gurol M Edip, Viswanathan Anand, Greenberg Steven M, Towfighi Amytis, Skolarus Lesli, Anderson Christopher D, Rosand Jonathan, Biffi Alessandro
From the Henry and Allison McCance Center for Brain Health (J.R.A., J.P.C., S.K., C.K., E.P.M., H.A., J.Q.A.H., C.D.A., J.R., A.B.), Department of Neurology (J.R.A., J.P.C., S.K., C.K., E.P.M., H.A., A.D.W., J.Q.A.H., M.E.G., A.V., S.M.G., C.D.A., J.R., A.B.), and Center for Genomic Medicine (J.R.A., S.K., C.K., E.P.M., J.Q.A.H., C.D.A., J.R., A.B.), Massachusetts General Hospital, Boston; School of Medicine (A.R.-T.), University of California, Irvine; Department of Neurology (A.T.), Keck School of Medicine, University of Southern California, Los Angeles; Los Angeles County Department of Health Services (A.T.), CA; Stroke Program (L.S.), University of Michigan Medical School, Ann Arbor; and Department of Neurology (C.D.A.), Brigham and Women's Hospital, Boston, MA.
Neurology. 2022 Mar 29;98(13):e1349-e1360. doi: 10.1212/WNL.0000000000200003. Epub 2022 Feb 7.
Although blood pressure (BP) control is considered the most effective measure to prevent functional decline after intracerebral hemorrhage (ICH), fewer than half of survivors achieve treatment goals. We hypothesized that long-term (i.e., prehemorrhage) hypertension severity may be a crucial factor in explaining poor BP control after ICH. We investigated changes in hypertension severity after vs before ICH using latent class analysis (LCA) and identified patient characteristics predictive of individuals' BP trajectories.
We analyzed data for ICH survivors enrolled in a study conducted at Massachusetts General Hospital (MGH) from 2002 to 2019 in Boston, a high-resource setting with near-universal medical insurance coverage. We captured BP measurements in the 12 months preceding and following the acute ICH hospitalization. Using LCA, we identified patient groups (classes) based on changes in hypertension severity over time in an unbiased manner. We then created multinomial logistic regression models to identify patient factors associated with these classes.
Among 336 participants, the average age was 74.4 years, 166 (49%) were male, and 288 (86%) self-reported White race/ethnicity. LCA identified 3 patient classes, corresponding to minimal (n = 114, 34%), intermediate (n = 128, 38%), and substantial (n = 94, 28%) improvement in hypertension severity after vs before ICH. Survivors with undertreated (relative risk ratio [RRR] 0.05, 95% CI 0.01-0.23) or resistant (RRR 0.03, 95% CI 0.01-0.06) hypertension before ICH were less likely to experience substantial improvement afterwards. Residents of high-income neighborhoods were more likely to experience substantial improvement (RRR 1.14 per $10,000, 95% CI 1.02-1.28). Black, Hispanic, and Asian participants with uncontrolled hypertension before ICH were more likely to experience minimal improvement after hemorrhagic stroke (interaction < 0.001).
Most ICH survivors do not display consistent improvement in hypertension severity after hemorrhagic stroke. BP control after ICH is profoundly influenced by patient characteristics predating the hemorrhage, chiefly prestroke hypertension severity and socioeconomic status. Neighborhood income was associated with hypertension severity after ICH in a high-resource setting with near-universal health care coverage. These findings likely contribute to previously documented racial/ethnic disparities in BP control and clinical outcomes following ICH.
尽管血压控制被认为是预防脑出血（ICH）后功能衰退的最有效措施，但不到一半的幸存者能够达到治疗目标。我们推测长期（即出血前）高血压严重程度可能是解释脑出血后血压控制不佳的关键因素。我们使用潜在类别分析（LCA）研究了脑出血前后高血压严重程度的变化，并确定了预测个体血压轨迹的患者特征。
我们分析了2002年至2019年在波士顿马萨诸塞州总医院（MGH）进行的一项研究中纳入的脑出血幸存者的数据，该地区资源丰富，医疗保险覆盖率接近100%。我们记录了急性脑出血住院前后12个月内的血压测量值。使用LCA，我们以无偏倚的方式根据高血压严重程度随时间的变化确定患者组（类别）。然后我们创建多项逻辑回归模型，以确定与这些类别相关的患者因素。
在336名参与者中，平均年龄为74.4岁，166名（49%）为男性，288名（86%）自我报告为白人种族/族裔。LCA确定了3个患者类别，分别对应脑出血后与脑出血前相比高血压严重程度最小改善（n = 114，34%）、中度改善（n = 128，38%）和显著改善（n = 94，28%）。脑出血前高血压治疗不足（相对风险比[RRR] 0.05，95% CI 0.01 - 0.23）或难治性高血压（RRR 0.03，95% CI 0.01 - 0.06）的幸存者，之后经历显著改善的可能性较小。高收入社区的居民更有可能经历显著改善（每增加10,000美元RRR为1.14，95% CI 1.02 - 1.28）。脑出血前高血压未得到控制的黑人、西班牙裔和亚洲参与者，出血性中风后经历最小改善的可能性更大（交互作用<0.001）。
大多数脑出血幸存者在出血性中风后高血压严重程度并未持续改善。脑出血后的血压控制受到出血前患者特征的深刻影响，主要是中风前高血压严重程度和社会经济地位。在一个医疗保健覆盖率接近100%的高资源环境中，社区收入与脑出血后的高血压严重程度相关。这些发现可能导致先前记录的脑出血后血压控制和临床结果方面的种族/族裔差异。
