Real-world analysis of two ischaemic stroke and TIA systolic blood pressure goals on 12-month mortality and recurrent vascular events

Introduction Whether obtaining the more intensive goal systolic blood pressure(SBP)of<130mm Hg,rather than a less intensive SBP goal of<140mm Hg poststroke/transient ischaemic attack(TIA)is associated with incremental mortality and recurrent vascular event benefit is largely unexplored using real-world data.Lowering SBP excessively may result in poorer outcomes.Methods This is a retrospective cohort study of 26368 Veterans presenting to a Veterans Administration Medical Center(VAMC)with a stroke/TIA between October 2015 and July 2018.Patients were excluded from the study if they had missing or extreme BP values,receiving dialysis or palliative care,left against medical advice had a cancer diagnosis,were cared for in a VAMC enrolled in a stroke/TIA quality improvement initiative,died or had a cerebrovascular or cardiovascular event within 90 days after their index stroke/TIA.The analytical sample included 12337 patients.Average SBP during 90 days after discharge was assessed in categories(≤105mm Hg,106–115mm Hg,116–130mm Hg,131–140mm Hg and>140mm Hg).Separate multivariable Cox proportional hazard regressions were used to examine the relationship between average SBP groups and time to:(1)mortality and(2)any recurrent vascular event,from 90 days to up to 365 days after discharge from the index emergency department visit or inpatient admission.Results Compared with those with SBP>140mm Hg,patients with SBP between 116 and 130mm Hg had a significantly lower risk of recurrent stroke/TIA(HR 0.77,95%CI 0.60 to 0.99)but not cardiovascular events.Patients with SBP lower than 105mm Hg,compared with those with>140mm Hg demonstrated a statistically significant higher risk of death(HR 2.07,95%CI 1.43 to 3.00),but no statistical differences were found in other SBP groups.Discussion Data support a more intensive SBP goal to prevent recurrent cerebrovascular events among stroke/TIA patients by 90 days poststroke/TIA compared with less intensive goal.Very low SBPs were associated with increased mortality risk.

Association between admission haematocrit and mortality among men with acute ischaemic stroke

Objective Anaemia is associated with higher mortality among patients with non-stroke cardiovascular conditions;less is known regarding the relationship between anaemia and mortality among patients with acute ischaemic stroke.Methods Medical records were abstracted for n=3965 veterans from 131 Veterans Health Administration facilities who were admitted with ischaemic stroke in fiscal year 2007.Haematocrit values within 24 hours of admission were classified as≤27%,28%-32%,33%-37%,38%-42%,43%-47% or≥48%.Multivariate logistic regression was used to examine the relationship between anaemia and in-hospital,30-day,6-month and 1-year mortality,adjusting for age,medical comorbidities,modified Acute Physiology and Chronic Health Evaluation-III and stroke severity.Impact factors were calculated to standardise comparisons between haematocrit tier and other covariates.results Among n=3750 patients included in the analysis,the haematocrit values were≤27%in 2.1%(n=78),28%-32% in 6.2%(n=234),33%-37%in 17.9%(n=670),38%-42% in 36.4%(n=1366),43%-47% in 28.2%(n=1059)and≥48% in 9.1%(n=343).Patients with haematocrit≤27%,compared with patients in the 38%-42% range,were more likely to have died across all follow-up intervals,with statistically significant adjusted ORs(aORs)ranging from 2.5 to 3.5.Patients with polycythaemia(ie,haematocrit≥48%)were at increased risk of in-hospital mortality(aOR=2.9;95%CI 1.4 to 6.0),compared with patients with mid-range admission haematocrits.Pronounced differences between patients receiving and not receiving blood transfusion limited our ability to perform a propensity analysis.Impact factors in the 1-year mortality model were 0.46(severe anaemia),0.06(cancer)and 0.018(heart disease).Conclusions Anaemia is independently associated with an increased risk of death throughout the first year post stroke;high haematocrit is associated with early poststroke mortality.Severe anaemia is associated with 1-year mortality to a greater degree than cancer or heart disease.These data cannot address the question of whether interventions targeting anaemia might improve patient outcomes.