卒中后血压节律紊乱及其与卒中预后的关系

Circadian rhythm disorder of blood pressure after stroke and its correlation with stroke prognosis

目的探讨急性缺血性卒中患者血压昼夜节律紊乱特征及其与卒中预后的关系。方法前瞻性纳入2019年10月至2020年1月于连云港市第一人民医院神经内科无卒中病史的高血压性首发缺血性卒中住院患者140例(高血压卒中组),同期纳入连云港市第一人民医院体检中心的单纯高血压者105例(高血压组)和正常血压者101例(正常血压组),共346例研究对象,入组72 h完成动态血压监测,依据白天至夜间收缩压下降幅度进一步将患者分为超杓形、杓形、非杓形和反杓形血压4组,并于入组3、6、9、12个月随访主要终点事件(卒中发作)和次要终点事件(非致死性心肌梗死、心衰住院、心源性死亡和全因死亡)。采用单因素Cox回归分析筛选终点事件的可能危险因素,采用多因素Cox回归分析研究血压昼夜节律与终点事件的关系,采用Kaplan-Meier曲线显示不同血压昼夜节律终点事件的累积发生率。结果共纳入346例患者。高血压卒中组杓形血压占23.6%,显著低于高血压组(43.8%,P=0.001)和正常血压组的(68.3%,P<0.001);高血压卒中组非杓形和反杓形血压分别占41.4%和20.7%,显著高于正常血压组(19.8%、6.9%;P<0.001,P=0.003),而与高血压组(31.4%、13.3%)比较差异无统计学意义(P=0.109、0.133);多因素Cox回归显示,调整混杂因素后,反杓形血压与主要终点事件(HR=5.177,P=0.047)和次要终点事件(HR=4.909,P=0.022)均独立相关;反杓形血压的主要终点事件(Log Rank P=0.020)和次要终点事件(Log Rank P=0.011)累积风险显著高于杓形血压。结论急性缺血性卒中血压昼夜节律紊乱普遍存在,反杓型血压节律与卒中和心血管事件发作独立相关。

Objective To explore the circadian rhythm disorder characteristics of blood pressure in patients with acute ischemic stroke and its correlation with stroke prognosis.Methods A total of 346 subjects without a history of stroke were prospectively enrolled from the First People’s Hospital of Lianyungang between October 2019 and January 2020,and they were 140 hospitalized patients with hypertensive first-onset ischemic stroke(hypertensive stroke group),105 with simple hypertension(hypertensive group)and 101 cases with normal blood pressure(normal BP group).Ambulatory blood pressure monitoring was completed within 72 h after enrollment,then the patients were further divided into 4 groups based on the reduction of systolic BP from day to night:extreme-dipper,dipper,non-dipper,and reverse-dipper.The primary endpoint event(re-attack of stroke)and secondary endpoint events(non-fatal myocardial infarction,hospitalization due to heart failure,cardiogenic death or all-cause death)were followed up at 3,6,9 and 12 months after enrollment.Univariate and multivariate Cox regression analyses were adopted respectively to screen the potential risk factors of endpoint events,and to analyze the correlation between circadian rhythm of blood pressure and endpoint events.Finally,Kaplan-Meier survival curve was used to display the cumulative incidence of endpoint events with different circadian rhythms of blood pressure.Results The dipper BP accounted for 23.6%in the hypertensive stroke group,which was significantly lower than that in the hypertension group(43.8%,P=0.001)and normal BP group(68.3%,P<0.001).The non-dipper and reverse-dipper BP in the hypertensive stroke group were 41.4%and 20.7%,respectively,greatly higher than those in the normal BP group(19.8%,P<0.001;6.9%,P=0.003),though there was no statistical significance in comparison with the hypertension group(31.4%,P=0.109;13.3%,P=0.133).Multivariate Cox regression revealed that after adjustment for confounding factors,the reverse-dipper BP was independently correlated with both the primary endpoint events(HR=5.177,P=0.047)and the secondary endpoint events(HR=4.909,P=0.022).Moreover,the cumulative risks of both primary endpoint events(Log Rank P=0.020)and secondary endpoint events(Log Rank P=0.011)were notably increased in the reverse-dipper BP group than the dipper BP group.Conclusion Circadian rhythm disorder of blood pressure is prevalent among patients with acute ischemic stroke,and reverse-dipper BP rhythm is independently correlated with stroke onset and cardiovascular events.