Selker H P, Beshansky J R, Schmid C H, Griffith J L, Longstreth W T, O'Connor C M, Caplan L R, Massey E W, D'Agostino R B, Laks M M
Department of Medicine, New England Medical Center, Boston, MA 02111.
Circulation. 1994 Oct;90(4):1657-61. doi: 10.1161/01.cir.90.4.1657.
In selecting patients with acute myocardial infarction for thrombolytic therapy, it is important to identify patients who are at high risk for intracranial hemorrhage, for whom thrombolytic therapy is ill advised. We hypothesized that presenting pulse blood pressure, representing the "hammer" effect on cerebral vessels and the effects of age on arterial compliance, might predict thrombolysis-related intracranial hemorrhage better than systolic, diastolic, or mean arterial blood pressures.
Of 3483 Thrombolytic Predictive Instrument (TPI) Project subjects receiving thrombolytic therapy for acute infarction, we identified and obtained detailed clinical data on the 19 with treatment-related intracranial hemorrhages confirmed by computed tomography and on 175 matched controls. Systolic, diastolic, mean arterial, and pulse blood pressures were each significantly related to the occurrence of intracranial hemorrhage, with pulse pressure most highly related. The mean pulse pressure in patients who developed intracranial hemorrhage was 63 mm Hg, 34% higher than the 47 mm Hg mean value for those not developing hemorrhage (P = .0001). Excess pulse pressure, defined as the extent to which a patient's pulse pressure exceeded 40 mm Hg for systolic blood pressures of at least 120 mm Hg, was even more strongly related: its mean value of 23 mm Hg for patients was 130% higher than its mean value of 10 mm Hg for controls (P < .0001). With logistic regression models to estimate the relative risks (odds ratios) for intracranial hemorrhage conferred by each form of blood pressure, the relative risk for hemorrhage was greatest for excess pulse pressure: for each 10-point pulse pressure excess, the relative risk for intracranial hemorrhage was increased by 1.85 (P = .0002; 95% confidence interval [CI], 1.34 to 2.55) by itself and 1.76 (P = .001; 95% CI, 1.26 to 2.46) when adjusted for age. In this sample, excess pulse pressure by itself predicted hemorrhage as well as systolic pressure and age together. When excess pulse pressure was combined with age to make a logistic regression model predicting intracranial hemorrhage, age contributed less to the prediction than when combined with the other blood pressure forms, even though this model predicted better than any other combination of age and pressure (receiver-operating characteristic curve area, 0.82 versus 0.77 with systolic pressure and age, 0.75 with mean arterial pressure, 0.71 with diastolic pressure, and 0.81 with both systolic and diastolic pressures).
We found that excess pulse blood pressure predicted thrombolysis-related intracranial hemorrhage better than other forms of pretreatment blood pressure, perhaps better describing the pathophysiology of intracranial hemorrhage, including the effect of age. These findings will need confirmation in larger studies with comparable clinical detail.
在选择急性心肌梗死患者进行溶栓治疗时，识别颅内出血高危患者非常重要，这类患者不建议进行溶栓治疗。我们推测，就诊时的脉压代表对脑血管的“锤击”效应以及年龄对动脉顺应性的影响，可能比收缩压、舒张压或平均动脉压更能预测溶栓相关的颅内出血。
在3483例接受急性梗死溶栓治疗的溶栓预测工具（TPI）项目受试者中，我们确定并获取了19例经计算机断层扫描证实有治疗相关颅内出血患者以及175例匹配对照的详细临床数据。收缩压、舒张压、平均动脉压和脉压均与颅内出血的发生显著相关，其中脉压相关性最高。发生颅内出血患者的平均脉压为63mmHg，比未发生出血患者的47mmHg平均值高34%（P = .0001）。将脉压超过40mmHg（收缩压至少为120mmHg时）定义为脉压过高，其相关性更强：患者的平均脉压23mmHg比对照组的平均值10mmHg高130%（P < .0001）。通过逻辑回归模型估计每种血压形式导致颅内出血的相对风险（比值比），脉压过高导致出血的相对风险最大：每增加10个单位的脉压过高，颅内出血的相对风险自身增加1.85（P = .0002；95%置信区间[CI]，1.34至2.55），调整年龄后增加1.76（P = .001；95%CI，1.26至2.46）。在这个样本中，脉压过高自身对出血的预测能力与收缩压和年龄联合起来相当。当将脉压过高与年龄结合构建预测颅内出血的逻辑回归模型时，年龄对预测的贡献比与其他血压形式结合时小，尽管该模型的预测效果优于年龄与其他血压形式的任何其他组合（受试者工作特征曲线下面积，脉压过高与收缩压和年龄联合时为0.82，收缩压和年龄联合时为0.77，平均动脉压联合时为0.75，舒张压联合时为0.71，收缩压和舒张压联合时为0.81）。
我们发现脉压过高比其他形式的治疗前血压更能预测溶栓相关的颅内出血，可能更好地描述了颅内出血的病理生理学，包括年龄的影响。这些发现需要在具有可比临床细节的更大规模研究中得到证实。
