缺血性脑卒中早期血压水平对大脑与肾脏血流灌注的影响

Effect of blood pressure on cerebral and renal perfusion of patients in early stage of Ischemic stroke

目的探索缺血性脑卒中早期血压水平对大脑与肾脏血流灌注的影响和合理的血压管理方法。方法入选发病24 h内首发急性脑卒中患者873例,根据入院时血压水平分为静脉降压组、口服降压组和观察组,并将全组血压值分为7个水平统计。于发病3、6、12、24 h动态监测血压,同步检测肾小球滤过率（glomerular filtration rate,GFR）、颈内动脉流量（internal carotid artery flow,ICAF）,采用单因素与多因素COX比例风险模型分析血压水平与判定为灌注良好、灌注不足和灌注衰退之灌注结果的概率。结果入院时静脉降压组血压水平显著高于口服降压组（P〈0.05）。2组给药时间相当情况下,静脉降压组血压水平降至（143.2±13.7）/（93.6±10.2）mm Hg,显著低于口服降压组（153.7±12.8）/（106.3±11.6）mm Hg（P〈0.01）。在收缩压（SBP）140~159 mm Hg和舒张压（DBP）90~99 mm Hg组,灌注良好的概率最高且灌注不足与灌注衰退的风险最低;而在SBP≥180 mm Hg和DBP≥110 mm Hg以上组,灌注良好的概率较低且灌注不足与灌注衰退的风险较高,剔除潜在的混杂因素后这种关系依然存在。结论缺血性脑卒中早期血压水平与脑、肾血流灌注密切相关。对入院血压≥180/110 mm Hg的患者,于发病24 h内给予静脉降压治疗,使其血压维持在140~159/90~99 mm Hg的＂轻度高血压水平＂,有利于脑、肾血流灌注。

Objective To explore the effect of blood pressure on the cerebral and renal perfusion of patients in early stage of ischemic stroke,and find an optimal blood pressure management method. Methods In the study,873 patients with first onset of cerebral infarction within 24 h were selected,and divided into an intravenous antihypertensive group,an oral antihypertensive group and an observation group based on the blood pressure at admission. The blood pressure values were divided into 7 levels. The blood pressure at 3,6,12,and 24 h after cerebral infarction onset was dynamically monitored,and the glomerular filtration rate（ GFR） and internal carotid artery flow（ ICAF） were synchronously detected. The correlation of blood pressure levels and probability of perfusion outcomes（ good perfusion,inadequate perfusion and perfusion recession） was analyzed using univariate and multivariate COX proportional hazard analysis. Results The blood pressure at admission in the intravenous antihypertensive group was（ 184. 5 ± 23. 6） mm Hg /（ 123. 7 ±15. 4） mm Hg,significantly higher than（ 167. 3 ± 18. 5） mm Hg /（ 112. 1 ± 14. 2） mm Hg in the oral antihypertensive group（ P〈0. 05）. After the same administration time,the blood pressure level of the intravenous antihypertensive group decreased to（ 143. 2 ± 13. 7） mm Hg /（ 93. 6 ± 10. 2） mm Hg,significantly lower than（ 153. 7 ± 12. 8） mm Hg /（ 106. 3 ± 11. 6） mm Hg of the oral antihypertensive group（ P〈0. 01）.The probability of good perfusion was the highest and the risk of inadequate perfusion and perfusion recession was lowest in the group with systolic blood pressure（ SBP） 140- 159 mm Hg and diastolic blood pressure（ DBP） 90- 99 mm Hg. However,the probability of good perfusion was the lowest and the risk of inadequate perfusion and perfusion recession was highest in the group with SBP ≥180 mm Hg and DBP ≥110 mm Hg.The results were the same even if potential confounding factors were removed. Based on the C-statistics,the odds ratios of SBP and DBP were 0. 571 and 0. 574,respectively,at good neurological recovery,1. 541 and1. 678 at neurological deterioration,and 1. 523 and 1. 556 at poor functional outcome. Conclusion The blood pressure level in early stage of ischemic stroke is closely correlated with cerebral and renal perfusion.Maintaining blood pressure at the mild hypertension level（ 140- 159 /90- 99 mm Hg） to provide intravenous antihypertensive therapy within 24 hours will be helpful to the cerebral and renal perfusion for the patients with blood pressure ≥180 /110 mm Hg at admission.