【作者】 李静；

【导师】 林永忠；

【作者基本信息】 大连医科大学 ， 神经病学， 2022， 硕士

【摘要】 背景:急性缺血性卒中(acute ischemic stroke,AIS)患者接受重组组织型纤维蛋白酶原激活剂(recombinant tissue plasminogen activator,rt-PA)静脉溶栓治疗后血压对预后的影响,不同的临床试验得出结论不同。本研究旨在探讨溶栓后血压对不同严重程度的AIS患者预后的影响,并进一步确定AIS溶栓患者的理想血压管理值。方法:回顾性纳入2018年1月-2021年3月于大连医科大学附属第二医院接受标准剂量rt-PA静脉溶栓治疗的307例AIS患者,记录溶栓后24小时内的血压水平,计算平均收缩压和平均舒张压。同时,记录患者年龄、性别、基线美国国立卫生研究院卒中量表(National Institutes of Health Stroke,NIHSS)评分、医院就诊到溶栓治疗开始的时间(door-to-needle time,DNT)、高血压病史、糖尿病史、房颤病史、缺血性心脏病史、吸烟史、饮酒史、血糖、糖化血红蛋白、总胆固醇、甘油三酯、低密度脂蛋白、高密度脂蛋白、梗死面积、梗死部位、责任血管狭窄、出院时(7±2天)时NIHSS评分、颅内出血转化和死亡。主要结局变量为出院时神经功能改善良好,次要结局变量为:颅内出血转化和死亡,分别根据上述3个结局变量对患者进行分组。先对307例AIS溶栓患者进行统计学分析(单因素+多因素),探讨血压对预后的影响。再对轻型(NIHSS评分≤5分,N=200人)和中重型卒中(NIHSS>5分,N=107人)患者进行统计学分析,分别探讨血压对他们预后的影响,并将血压转变为分类变量寻找理想血压管理值。结果:1.对纳入的307例AIS溶栓患者进行单因素分析,结果表明神经功能改善良好组患者的平均收缩压低于神经功能改善不良组(144±15mm Hg vs 150±15 mm Hg,P<0.001);颅内出血转化组患者的平均收缩压高于非颅内出血转化组患者(157±11mm Hg vs 146±16mm Hg,P=0.001);死亡组患者的平均收缩压高于生存组患者(159±16mm Hg vs 146±15mm Hg,P=0.001),以上差异均有统计学意义。进一步进行多因素的Logistic回归分析校正协变量,结果表明平均收缩压是神经功能改善良好的独立影响因素(OR=0.981,95%Cl 0.965-0.998,P=0.03),而平均收缩压与颅内出血转化/死亡之间无独立相关性(P>0.05)。2.对200例轻型卒中患者,单因素分析结果表明神经功能改善良好组和神经功能改善不良组,颅内出血转化组和非颅内出血转化组在平均收缩压、平均舒张压上的差异均无统计学意义(P>0.05)。3.对107例中重型卒中患者,单因素分析结果表明神经功能改善良好组患者的平均收缩压低于神经功能改善不良组(144±15mm Hg vs 151±16mm Hg,P=0.002);颅内出血转化组患者的平均收缩压高于非颅内出血转化组患者(158±12 mm Hg vs149±16mm Hg,P=0.037);死亡组患者的平均收缩压高于生存组患者(159±16 mm Hg vs 149±16mm Hg,P=0.037),以上差异均有统计学意义。进一步调整协变量后,多因素分析结果表明平均收缩压是神经功能改善良好的独立影响因素(OR=0.966,95%Cl:0.937-0.996,P=0.026)。根据平均收缩压五等分患者,将平均收缩压作为分类变量进行多因素分析,结果表明Q1(平均收缩压<138mm Hg)、Q2(平均收缩压为138-147mm Hg)、Q3组(平均收缩压为148-154mm Hg)的神经功能改善良好率高于Q5组(平均收缩压>165mm Hg),且差异有统计学意义(OR=4.64,95%Cl:1.055-20.42,P=0.042;OR=9.227,95%Cl:1.948-43.718,P=0.005;OR=8.921,95%Cl:1.891-42.081,P=0.006)。Q4组(平均收缩压为155-165mm Hg)的神经功能改善良好率略高Q5组,但差异无统计学意义(P>0.05)。平均收缩压与调整后的OR值呈N型相关,Q2组神经功能改善良好率最高。结论:1.溶栓后24小时内的平均收缩压与AIS溶栓患者近期预后独立相关。2.溶栓后血压对轻型卒中患者的预后无影响。3.溶栓后平均收缩压是中重型卒中患者近期预后的独立影响因素,其理想的血压管理值为138-147mm Hg。更多还原

【Abstract】 Background: Regarding the relationship between blood pressure and prognosis in patients with acute ischemic stroke(AIS)receiving recombinant tissue plasminogen activator(rt-PA)intravenous thrombolysis,different clinical trials have obtained different conclusion.The aim of this study was to explore the effect of blood pressure after thrombolysis on the prognosis of patients with AIS of different severity,and to further determine the ideal blood pressure management value for AIS patients undergoing thrombolysis.Methods: We retrospectively enrolled 307 AIS thrombolysis patients who received standard-dose rt-PA intravenous thrombolysis in the Second Affiliated Hospital of Dalian Medical University from January 2018 to March 2021.We recorded the blood pressure levels within the first 24 hours after thrombolysis to calculate the average systolic blood pressure and diastolic blood pressure.In the meanwhile,The following data were recorded,including age,gender,baseline National Institutes of Health Stroke(NIHSS)score,door-to-needle time(DNT),hypertension,diabetes mellitus,atrial fibrillation,ischemic heart diseases,smoking,drinking,blood glucose,glycosylated hemoglobin,total cholesterol,total triglyceride,low-density lipoprotein,high-density lipoprotein,infarct area,infarct size and caused vascular stenosis,NIHSS score at discharge,death and intracranial hemorrhage.The primary outcome variable was favorable neurological improvement at discharge,and the secondary outcomes were intracranial hemorrhage and death.Patients were grouped according to the three above outcome variables.First,307 candidates were statistically analyzed(univariate analysis+ multivariate analysis)to explore the influence of blood pressure on prognosis.Next,we performed statistical analysis on patients with mild(NIHSS score ≤5,N=200)and moderate-to-severe stroke(NIHSS>5,N=107)patients,respectively,to explore the effect of blood pressure on their prognosis.Then we turn blood pressure into a categorical variable to find the ideal blood pressure management value.Results:1.A total of 307 subjects were finally included.The results of univariate analysis showed that the systolic blood pressure in the favorable neurological improvement group was significantly lower than that in the unfavorable neurological improvement group(144±15mm Hg vs 150±15 mm Hg,P<0.001).The mean systolic blood pressure in the patients with intracranial hemorrhage transformation group was higher than that in the nonintracranial hemorrhagic transformation group(157±11mm Hg vs 146±16mm Hg,P=0.001).The mean systolic blood pressure in the death group was higher than that in the survival group(159±16mm Hg vs 146±15mm Hg,P=0.001).Further multivariate Logistic regression analysis,after adjusting for covariates,found that the average systolic blood pressure was an independent factor for the favorable neurological improvement(OR=0.981,95% Cl 0.965-0.998,P=0.03).However,there was no independent correlation between average systolic blood pressure and intracranial hemorrhagic transformation and death(P>0.05).2.For 200 patients with mild stroke,the mean systolic and diastolic blood pressure were not significantly different between favorable and unfavorable neurological improvement group(P=0.53;P=0.69)and between intracranial hemorrhage transformation group and non-intracranial hemorrhagic transformation group.3.For 107 patients with moderate-to-severe stroke,the results of univariate analysis showed that the systolic blood pressure in the favorable neurological improvement group was significantly lower than that in the unfavorable neurological improvement group(144±15mm Hg vs 151±16mm Hg,P=0.002).The mean systolic blood pressure in the patients with intracranial hemorrhage transformation group was higher than that in the non-intracranial hemorrhagic transformation group(158±12 mm Hg vs 149±16mm Hg,P=0.037).The mean systolic blood pressure in the death group was higher than that in the survival group(159±16 mm Hg vs 149±16mm Hg,P=0.037).After further adjusting for covariates,multivariate analysis showed that average systolic blood pressure was an independent factor for the favorable neurological improvement(OR=0.966,95%Cl:0.937-0.996,P=0.026).The patients were divided into five equal parts according to the average systolic blood pressure.Then the average systolic blood pressure was used as a categorical variable for multivariate analysis.The results showed that Q1(average systolic blood pressure <138mm Hg),Q2(average systolic blood pressure was 138-147 mm Hg),and Q3 group(average systolic blood pressure was 148-154 mm Hg)had a higher rate of favorable neurological improvement than Q5 group(average systolic blood pressure>165mm Hg),and these differences were statistically significant(OR=4.64,95%Cl: 1.055-20.42,P=0.042;OR= 9.227,95%Cl: 1.948-43.718,P=0.005;OR=8.921,95%Cl: 1.891-42.081,P=0.006).Compared with Q5 group,Q4 group(mean systolic blood pressure was 155-165 mm Hg)also was higher,but the difference was not statistically significant(P>0.05).The association between mean systolic blood pressure and adjusted OR values was N-shape,with the highest rate of favorable neurological improvement in the Q2 group.Conclusions:1.Average systolic blood pressure within 24 hours after thrombolysis was independently associated with short-term outcomes in patients with AIS thrombolysis.2.Blood pressure after thrombolysis had no effect on the prognosis of patients with mild stroke.3.for patients with moderate to severe stroke,average systolic blood pressure within 24 hours after thrombolysis was an independent factor for short-term prognosis,and the ideal blood pressure management value was 138-147 mm Hg.更多还原