不同病因首次缺血性脑卒中急性期血压与预后的关系

Relationship between acute blood pressure and prognosis in different subtypes of first ischemic stroke

目的研究不同病因首次缺血性脑卒中急性期血压的变化规律，并探讨其对预后的影响。方法首次急性缺血性脑卒中患者710例，动态监测入院7d内的血压。采用Barthel指数和美国国立卫生研究院卒中量表（NIHSS）评分联合评估患者脑卒中预后。大动脉粥样硬化型（LAA）400例，心源性栓塞型（CE）160例，小动脉病变闭塞型（sao）150例。采用多因素Logistic逐步回归分析不同病因学分型脑卒中患者预后的影响因素。结果各病因学分型入院时血压和急性期平均血压与预后均呈u型曲线关系。IJAA和cE以入院时收缩压在140～159mlnHg（1mmHg=0．133kPa）和舒张压在90～99mmHg预后最佳，SAO以入院时平均血压在130／95mmHg左右时预后最佳，各病因学分形入院时平均血压在150／95mmHg左右时患者预后不良率最低；LAA和CE以入院7d内平均收缩压在120～159mmHg和舒张压在80～99mmHg预后较好，SAO以入院7d内平均血压维持在140／90mmHg左右时预后良好率最高，各病因学分型入院7d内平均血压在140／90mmHg左右时预后最佳。多因素Logistic逐步回归分析发现：入院24h内血压下降水平过大、人院7d内病情加重、急性期出现并发症及入院时NIHSS评分皆为IAA和CE预后不良的独立危险因素，急性期降压治疗为其预后的独立保护因素；影响SAO预后的独立危险因素为急性期出现并发症。结论各病因学分型入院时血压和急性期平均血压与预后均呈U型曲线关系。血压过高或过低者预后均较差。对于LAA和CE患者，人院24h内血压下降水平过大、人院7d内病情加重、急性期出现并发症、人院时NIHSS评分皆为其预后的独立危险因素。

Objective To study the variation of acute blood pressure in different subtypes of first ischemic stroke, and investigate the influence on the prognosis. Methods A total of 710 patients with first ischemic stroke were selected. The blood pressure levels were monitored during the initial 7 hospital days. Clinical outcome was based on the combined analysis of Barthel index and the National Institute of Health Stroke Scale （NIHSS） score on the 180th day. In the subtypes of large artery atherothrombosis（LAA）, cardioembolism （ CE ）, small artery disease occlusion （SAO） were 400,160,150 cases. Logistic regression model was used to estimate the influencing factors on the prognosis. Results An U-shaped effect was observed in different subtypes between blood pressure on admission, average acute blood pressure and prognosis. In the subtypes of LAA and CE,those who had a baseline systolic blood pressure （SBP） of 140 - 159 mm Hg （ 1 mm Hg = 0.133 kPa） or a baseline diastolic blood pressure （DBP） of 90 - 99 mm Hgon admission got good prognosis. In the subtypes of SAO, those who had a baseline blood pressure of 130/95 mm Hg on admission got good prognosis. In all subtypes, the average blood pressure of 150/95 mm Hg got good prognosis. In the subtypes of LAA and CE,those who had a baseline SBP of 120 -159 mm Hg or a baseline DBP of 80 - 99 mm Hg within 7 d after admission got good prognosis. In the subtypes of SAO, those who had a baseline blood pressure of 140/90 mm Hg within 7 d after admission got good prognosis. In all subtypes, the average blood pressure of 140/90 mm Hg within 7 d after admission got good prognosis. Logistic regression analysis revealed that the decrease of blood pressure during the first 24 hours, deterioration within 7 d after admission, acute complication, NIHSS score on admission were the independent risk factors of prognosis,while antihypertensive therapy in the acute phase was the independent protection factor in the subtypes of LAA and CE. In the subtypes of SAO, acute complication was the independent risk factor of prognosis. Conclusions An U-shaped effect is observed in different subtypes between blood pressure on admission and prognosis. In the subtypes of LAA and CE, the decrease of blood pressure during the first 24 hours,deterioration within 7 d after admission, acute complication, NIHSS score on admission are the independent risk factors of prognosis.