缺血性脑卒中急性期血压与静脉溶栓后早期神经功能改善的关联分析

Correlation between blood pressure and early neurological function improvement in patients with acute ischemic stroke after intravenous thrombolysis

目的分析急性缺血性脑卒中患者的急性期血压水平与静脉溶栓后早期神经功能改善的关联,探索功能改善最佳的血压范围。方法基于观察性研究设计,纳入2018年1月至2021年12月就诊于北京市脑卒中急诊救治资质医院并接受静脉溶栓治疗的急性缺血性脑卒中患者。采用美国国立卫生研究院卒中量表(NIHSS)评分评估静脉溶栓治疗后2 h患者的神经功能状态,0~1分定义为早期神经功能改善,据此将患者分为早期神经功能改善(ENI)组(n=4780)与非ENI组(n=10,923)。利用多因素模型结合限制性立方样条分析拟合急性期血压水平与NIHSS评分的相关曲线,根据曲线拐点选取参考血压范围,采用多因素模型探索不同血压水平与早期神经功能改善的关联。结果研究共纳入15,703例急性缺血性脑卒中患者,平均年龄为64.9岁,男性占69.2%。急性期平均收缩压为150.8 mmHg(1 mmHg=0.133kpa),平均舒张压为85.4 mmHg。4780例(30.4%)患者静脉溶栓后早期神经功能得到改善。急性期血压与静脉溶栓后2hNIHSS评分存在U形关联,急性期收缩压为156 mmHg,舒张压为96 mmHg时NIHSS评分最低。与145~165 mmHg相比,急性期收缩压<145 mmHg或>165 mmHg的患者早期神经功能改善的比例更低[(OR=0.87,95%CI:0.80~0.95,P<0.05;OR=0.90,95%CI:0.82~0.99,P<0.05)];与90~100 mmHg相比,急性期舒张压<90 mmHg或>100 mmHg的患者早期神经功能改善的比例更低[(OR=0.86,95%CI:0.80~0.94,P<0.05;OR=0.91,95%CI:0.79~0.99,P<0.05)]。在不同性别、年龄、既往是否患有高血压的亚组人群中均显示上述关联。结论急性缺血性脑卒中患者急性期血压水平与静脉溶栓后早期神经功能改善存在非线性关联,最佳血压范围为145~165 mmHg/90~100 mmHg,较高或较低的急性期血压水平均不利于早期神经功能改善。

Objective To analyze the correlation between blood pressure(BP)level and early neurological function improvement in patients with acute ischemic stroke(AIS)after intravenous thrombolysis,and study the optimal range of BP for neurological function improvement.Methods Based on observational study design,AIS patients received intravenous thrombolysis were chosen Beijing qualified hospital for emergency stroke treatment from 2018 to 2021.The neurological status of patients 2 h after intravenous thrombolysis was assessed through scoresof National Institute of Health Stroke Scale(NIHSS),and scores of 0 to 1 were defined as early neurological improvement.The correlation curve between BP level and NIHSS scores wasfitted by using multi-factor model combined with restricted cubic spline analysis.The reference BP range was selected according to the inflection point of the correlation curve.The correlation between different BP levels and early neurological function improvement was studied by using multi-factor model.Results There were totally 15,703 AIS patients included,the average age was 64.9 years old,and male cases accounted for 69.2%.The mean systolic pressure(MSP)was 150.8 mmHg and mean diastolic pressure(MDP)was 85.4 mmHg in acute stage.The early neurological function was improved in 4,780 patients(30.4%)after intravenous thrombolysis.There was a U-shaped correlation between BP and NIHSS scores 2 h after intravenous thrombolysis.NIHSS scores were the lowest when systolic blood pressure(SBP)was 156 mmHg and diastolic blood pressure(DBP)was 96 mmHg in acute stage.The percentages of patients with SBP<145 mmHg or SBP>165 mmHg were lower compared with those with SBP145~165 mmHg[(OR=0.87,95%CI:0.80~0.95,P<0.05;OR=0.90,95%CI:0.82~0.99,P<0.05)].The percentages of patients with DBP<90 mmHg or DBP>100 mmHg were lower compared with those with DBP 90~100 mmHg[(OR=0.86,95%CI:0.80~0.94,P<0.05;OR=0.91,95%CI:0.79~0.99,P<0.05)].The above-mentioned correlations were also observed in subgroups of different sex,age and hypertension history.Conclusion There is a nonlinear correlation between BP level in acute stage and early neurological function improvement in AIS patients after intravenous thrombolysis.The optimal BP range is 145~165 mmHg and 90~100 mmHg.The higher or lower BP levels in acute stage is not conducive to early neurological function improvement.