| Background and purpose:Hypertention and hyperglycemia are the most important risk factors for the incidence of stroke, but the relationship between hypertension and hyperglycemia in the acute phase and clinical outcome of acute stroke is still inconclusive. We studied the association between hypertension and hyperglycemia in acute phase and the clinical outcome in-hospital or in the first 3 months after stroke onset among ischemic and hemorrhagic stroke patients to provide scientific evidence for the effective controlling of blood pressure (BP) and fast plasme glucose (FPG) in the acute phase of stroke.Method:1. Retrospective cohort studyA total of 2,178 ischemic stroke patients and 1,760 hemorrhagic stroke patients in six hospitals from January, 2003 to December, 2005 were included in the present study. Demographic characteristics, lifestyle factors, BP and laboratory examinations at admission, medical history, and clinical outcome were collected by referring to the medical records. Clinical outcome was defined as in-hospital death or dependency [Modified Rankin’s scale (MRs) >2] at discharge. Statistic analysis was conducted using SPSS 15.0 software. Difference of the baseline characteristics were compared between acute ischemic and hemorrhagic stroke patients and between patients with and without outcomes. Unadjusted and multiple adjusted logistic regression models were used to analyze the relationship between BP and FPG at admission and in-hospital death or dependency among acute ischemic and hemorrhagic stroke patients, which were evaluated by the odds ratio (OR) and 95% confident interval (95% CI).2. Prospective cohort study Subjects in the control group of the China stroke project (A randomized controlled trial of reducing BP among acute ischemic stroke patients) which conducted by China and America cooperation were served as subjects in the present study. According to the guideline of the project, patients in the control group were forbidden to use medicine to lower blood pressure on admission. A totle of 590 patients in the case group and 587 patients in the control group were obtained from August 1st, 2009 to March 31th, 2011 in the project. The 587 ischemic patients in the control group were served as study subjects in the present study to explore the relationship between BP and FPG in acute phase and short-term outcome and 3 months outcome among ischemic stroke patients. Demographic characteristics, lifestyle factors, laboratory examinations at admission, medical history and death, NIHSS score, MRs score were collected. The FPG in the first 24 hours was examined, the BP in the first 24 hours (one measurement every two hours) and from the 1st to the 14th day after admission were monitored for all subjects. Follow-up study was conducted in the 3rd month after stroke onset among all the participants, clinical outcome during this period and NIHSS score, MRs score were collected. Clinical outcome was defined as death or dependency (MRs>2). Statistic analysis was conducted using SAS 9.1 software. Difference of the baseline characteristics were compared between ischemic stroke patients with different BP levels and various clinical outcomes. Unadjusted and multiple adjusted Cox proportional hazard models were used to analyze the relationship between BP and FPG in the acute phase and clinical outcome in-hospital and in the 3rd month after stroke onset among ischemic stroke patients, which were evaluated by the relative risk (RR) and 95% CI.Results:1. BP in the acute phase and the clinical outcome of stroke patients1) Retrospective cohort studyThe case-fatality rate and disability rates were 1.8% and 41.3% in ischemic stroke patients and 5.9% and 34.4% in hemorrhagic stroke patients. The case-fatality rate was significantly higher in hemorrhagic stroke patients than in ischemic stroke patients (P <0.001). However, the disabilty rate was significantly higher in ischemic stroke patients than in hemorrhagic stroke patients (P <0.001). The rates of history of hypertension and diabetes were significantly higher in patients with clinical outcome than those in patients without clinical outcome among ischemic stroke patients, but difference in BP level between the two was not statistically significant. The rates of history of hypertension, mean level of systolic blood pressure (SBP), diastolic blood pressure (DBP) and pulse pressure (PP) were significantly higher in patients with clinical outcome than those in patients without clinical outcome among hemorrhagic stroke patients (64.7% vs. 57.3%, 177±34 mmHg vs. 169±35 mmHg, 106±20 mmHg vs. 102±19 mmHg, 71±23 mmHg vs. 67±24 mmHg, respectively). No significant difference was observed in other variables between the two. In acute hemorrhagic stroke patients, the SBP, DBP, and PP on admission were all significantly associated with the risk of death in-hospital. Compared with patients with SBP <140 mmHg, the multiple adjusted OR of death was 4.36 (2.12, 8.97) in patients with SBP≥200 mmHg (P <0.05). Compared with patients with DBP <90 mmHg, the multiple adjusted OR of death was 2.90 (1.47, 5.70) for patients with DBP≥120 mmHg (P <0.05). Compared with patients with PP <50 mmHg, the multiple adjusted OR of death or dependency was 1.56 (1.14, 2.14) in patients with PP≥70mmHg (P <0.05).The levels of SBP and DBP at admission were also significantly associated with the risk of dependency in-hospital in acute hemorrhagic stroke patients. Compared with patients with SBP <140 mmHg, the multiple adjusted ORs of dependency for the patients with SBP 140-159, 160-179, 180-199 and≥200 mmHg were 1.41 (0.97, 2.05), 1.52 (1.05, 2.19), 1.94 (1.33, 2.81) and 1.58 (1.10, 2.27), respectively, all P <0.05. Compared with patients with DBP <90 mmHg, the multiple adjusted ORs of dependency in DBP 90-99, 100-109, 110-119 and≥120 mmHg were 1.48 (1.03, 2.12), 1.63 (1.17, 2.28), 1.43 (0.99, 2.07), 1.69 (1.21, 2.35), respectively. The association between BP level at admission and risk of death in-hospital was not observed among acute ischemic stroke patients (P >0.05).2) Prospective cohort studyA totle of 587 ischemic stroke patients were recruited in the study, all participants completed the 14th day follow-up, and 531 patients completed the 3rd month follow-up study. The rates of follow-up were 100% for the 14th day and 90.46% for the 3rd month. The case-fatality and disablity rate were 3.92%, 26.74% in the first 14 days and 4.70%, 18.64% in the first 3 months, respectively. Patients died within the first 14 days had a higher level of mean SBP of the first 24 hours at admission than those with dependency or without clinical outcome (160 vs 158 vs 155 mmHg, P <0.05). Patients died within the first 3 months had a higher level of mean SBP and DBP of the first 24 hours at admission than those with dependency or without clinical outcome (162 vs 157 vs 155 mmHg, P <0.05). Patients died within the first 14 days or first 3 months had a higher SBP level in the 1st and the 5th day than those with dependency and without clinical outcome. We obeserved that levels of SBP and DBP among the first 14 days were apparently fluctuant in died patients, slight fluctuant in the disabled patients, and steady in patients without clinical outcome. Subjects were devided into three groups by admission BP (First group: SBP<160 mmHg and DBP<100 mmHg, Second group: SBP 160 mmHg -180 mmHg or DBP 100 mmHg-110 mmHg, Third group: SBP≥180 mmHg or DBP≥110 mmHg). Compared with the first group, the multiple adjusted RRs for dependency in first 14 days and for death in the first 3 months in the third group were statistically significant [RRs were 1.54(1.03, 2.31), 3.92(1.12, 13.67), respectively]. Subjects were devided into three groups by admission PP (First group: PP <60 mmHg, Second group: PP 60 mmHg -69 mmHg, Third group: PP≥70 mmHg). Compared with the first group, the multiple adjusted RR for dependency in the first 14 days was 1.56 (1.03, 2.35) in the third group.2. FPG in the acute phase and the clinical outcome of stroke patients1) Retrospective cohort studyCompared with patients with FPG <7.0 mmol/L, the ORs of death in-hospital for patients with FPG 7.0-7.7 mmol/L and FPG≥7.8 mmol/L were 7.205 (2.278, 22.782), 18.390 (6.292, 53.748) in ischemic stroke patients, and 2.770 (1.325, 5.791), 4.935 (2.027, 12.020) in hemoharrhagic stroke patients, respectively. The linear trends were also statistically significant.2) Prospective cohort studySubjects were devided into three groups by admission FPG (First group: FPG <5.6 mmol, Second group: FPG 5.6 mmol -7.0 mmol, Third group: FPG≥7.0 mmol). Compared with the first group, the multiple adjusted RR for death in first 14 days and the first 3 months were 2.98 (1.04, 8.53), 2.89 (0.85, 9.88) in the third group.Conclusion:Increased level of SBP, DBP, PP at admission were all positively and significantly associated with death and dependency among patients with hemorrhagic stroke. The ischemic stroke patients with hypertension in the first 24 hours after admission was associated with dependency in-hospital and death in the first 3 months. The ischemic stroke patients with high FPG at admission was associated with dependency and death in-hospital. We suggested that positive treatment lowering BP should be taken in hemoharrhagic stroke patients with acute hypertension and acute ischemic stroke patients with extremely high BP (SBP≥180 mmHg or DBP≥110 mmHg). BP should be measured and keep stable in the acute phase of acute ischemic stroke patients. We also suggested that positive treatment lowering FPG should be taken both in acute hemorrhagic and ischemic stroke patients. |
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