Association of characteristics of blood pressure profiles and stroke outcomes in the ECASS-II trial

Background and Purpose - Certain characteristics of early blood pressure (BP) profiles were reported to be independent predictors of long-term outcome in the first European Cooperative Acute Stroke Study (ECASS-I) trial. The aim of the study was to find out the association of BP profiles with functional outcome, mortality, and hemorrhagic complications in the ECASS-II database. Methods - We studied 793 patients with acute ischemic hemispheric stroke in the ECASS-II. After randomization, BP was measured every 15 minutes during the first 2 hours, then every 30 minutes during the first 8 hours, and thereafter at 1-hour intervals up to 24 hours. Individual 0- to 24- hour BP profiles were characterized by baseline, maximum, minimum, and mean BP and successive variation of the profile. The end points were favorable outcome (modified Rankin Scale score of 0 or 1) at day 90, all-cause mortality at day 90, and hemorrhagic transformation within the first 7 days. Results - High baseline, maximum, mean level, and variability of systolic BP profiles were each inversely associated with favorable outcome (OR = 0.84, 95% CI: 0.74 to 0.94; OR = 0.82, 95% CI: 0.73 to 0.91; OR = 0.81, 95% CI: 0.71 to 0.93; OR = 0.57, 95% CI: 0.35 to 0.92, respectively) and associated with an increased risk of parenchymal hemorrhage within the first 7 days (OR = 1.27, 95% CI: 1.07 to 1.51; OR = 1.49, 95% CI: 1.27 to 1.75; OR = 1.52, 95% CI: 1.23 to 1.87; OR = 2.62, 95% CI: 1.40 to 4.87; respectively) in recombinant tissue plasminogen activator-treated patients. In placebo-treated patients, high maximum, mean level, and successive variation of systolic BP profiles were inversely associated with favorable outcome (OR = 0.76, 95% CI: 0.66 to 0.86; OR = 0.76, 95% CI: 0.65 to 0.89; OR = 0.41, 95% CI: 0.22 to 0.76; respectively), although the association of baseline systolic BP and favorable outcome was not significant (OR = 0.91, 95% CI: 0.80 to 1.03). No association with hemorrhagic transformation was found, even after the adjustment. Conclusions - The hemorrhagic transformation within the first 7 days and favorable outcome were independently associated with dynamics of BP within the first 24 hours after an acute ischemic stroke in patients treated with thrombolysis, but in placebo-treated patients, only with favorable outcome. Continuous BP monitoring is hence important for the prognosis and gives implications to optimize BP management, particularly regarding a reasonable BP level and stability.