The management of blood pressure (BP) during the acute phase of stroke remains a matter of debate. The aim of the present study was to evaluate a possible association between long-term mortality and BP values in acute stroke by means of BP monitoring. We studied a consecutive series of 198 first-ever acute stroke patients. BP monitoring was initiated in all subjects within 24 h of ictus. One year after stroke onset, 34 (17.7%) patients had died. Multivariate Cox regression analysis revealed only age, level of consciousness on admission, lacunar stroke and 24-hour pulse pressure (24-hour PP) as significant outcome predictors. The hazards ratio for 1-year mortality associated with every 10 mm Hg increase in 24 h PP was 1.39 (95% CI: 1.04–1.86, p = 0.028). The present results demonstrate that increasing 24-hour PP levels in patients with acute stroke are independently associated with higher long-term mortality. This may have implications in acute stroke BP management and warrants further investigation.

Keywords:
Ischaemic stroke, Intracerebral haemorrhage, Pulse pressure, Blood pressure monitoring, Mortality, Outcome
1.
Bath FJ, Bath PMW: What is the correct management of blood pressure in acute stroke? The blood pressure in Acute Stroke Collaboration. Cerebrovasc Dis 1997;7:205–213.
2.
Yatsou FM; Zivin J: Hypertension in acute ischaemic strokes: Not to treat. Arch Neurol 1985;42:999–1000.
3.
Spence JD, Del Maestro RF: Hypertension in acute ischaemic strokes: Treat Arch Neurol 1985;42:1000–1002.
4.
Bath P: Alteplase not yet proven for acute ischaemic stroke. Lancet 1998;352:1238–1239.
5.
Slyter H: Ethical challenges in stroke research. Stroke 1998;29:1725–1729.
6.
Robinson TG, Dawson SL, Ahmed U, Manktelow B, Fortherby MD, Potter JF: Twenty-four hour systolic blood pressure predicts long-term mortality following acute stroke. J Hypertens 2001;19:2127–2134.
7.
Leonardi-Bee J, Bath PM, Phillips SJ, Sandercock PA: Blood pressure and clinical outcomes in the International Stoke Trial. Stroke 2002;33:1315–1320.
8.
Sorensen PS, Marquardsen J, Pedersen H, Heltberg A, Munck O: Long-term prognosis and quality of life after reversible cerebral ischemic attacks. Acta Neurol Scand 1989;79:204–213.
9.
Sacco RL, Shi T, Zamanillo MC, Kargman DE: Predictors of mortality and recurrence after hospitalized cerebral infarction in an urban community: The Northern Manhattan Stroke Study. Neurology 1994;44:626–634.
10.
Fiorelli M, Alperovitch A, Argentino C, Sacchetti ML, Toni D, Sette G, Cavalletti C, Gori MC, Fieschi C: Prediction of long-term outcome in the early hours following acute ischemic stroke. Italian Acute Stroke Study Group. Arch Neurol 1995;52:250–255.
11.
Irie K, Yamaguchi T, Minematsu K, Omae T: The J-curve phenomenon in stroke recurrence. Stroke 1993;24:1844–1849.
12.
Harper G, Fotherby MD, Panayiotou BJ, Castleden CM, Potter JF: The changes in blood pressure after acute stroke: Abolishing the ‘white coat effect’ with 24-h ambulatory monitoring. J Intern Med 1994;235:343–346.
13.
Coats AJ: Reproducibility or variability of casual and ambulatory blood pressure data: implications for clinical trials. J Hypertens Suppl 1990;8:S17–S20.
14.
Vemmos KN, Takis CE, Georgilis K, Zakopoulos NA, Lekakis JP, Papamichael CM, Zis VP, Stamatelopoulos S: The Athens stroke registry: Results of a five-year hospital-based study. Cerebrovasc Dis 2000;10:133–141.
15.
Lindestrom E, Boysen G, Christiansen LW, à Rogvi-Hansen B, Nielsen PW: Reliability of Scandinavian Neurological Stroke Scale. Cerebrovasc Dis 1991;1:103–111.
16.
Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, Marsh EE 3rd: Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 1993;24:35–41.
17.
World Health Organisation. Hypertension Control: Report of a WHO Expert Committee. Geneva, World Health Organisation, 1996.
18.
Hacke W, Kaste M, Skyhoj Olsen T, Bogousslavsky J, Orgogozo JM for the EUSI Executive Committee: Acute treatment of ischemic stroke. European Stroke Initiative (EUSI): Cerebrovasc Dis 2000;10(suppl 3):22–33.
19.
The NINDS rt-PA Stroke Study Group: Intracerebral hemorrhage after intravenous rt-PA therapy for ischemic stroke. Stroke 1997;28:2109–2118.
20.
Dul K, Drayer B: CT and MR imaging of intracerebral hemorrhage; in Kase CS, Caplan LR (eds): Intracerebral Hemorrhage. Boston, Butterworth-Heinemann, 1994, pp 73–93.
21.
Moulin T, Crepin-Leblond T, Chopard JL, Bogousslavsky J. Hemorrhagic infarcts. Eur Neurol 1994;34:64–77.
22.
Candelise L, Vigotti M, Fieschi C, Brambilla GL, Bono G, Conforti P, De Zanche L, Inzitari D, Mariani F, Prencipe M, et al: Italian multicenter study on reversible cerebral ischemic attacks. VI. Prognostic factors and follow-up results. Stroke 1986;17:842–848.
23.
Robinson T, Waddington A, Ward-Close S, Taub N, Potter J: The predictive role of 24-hour compared to casual blood pressure levels on outcome following acute stroke. Cerebrovasc Dis 1997;7:264–272.
24.
Wade DT, Langton-Hewer R, Wood VA: Stroke: the influence of age upon outcome. Age Ageing 1984;13:357–362.
25.
Vemmos KN, Bots ML, Tsibouris PK, Zis VP, Takis CE, Grobbee DE, Stamatelopoulos S: Prognosis of stroke in the south of Greece: 1-year mortality, functional outcome and its determinants: The Arcadia Stroke Registry. J Neurol Neurosurg Psychiatry 2000;69:595–600.
26.
Franklin SS, Gustin W, Wong ND, Larson MG, Weber MA, Kannel WB, Levy D: Hemodynamic patterns of age-related changes in blood pressure. The Framingham Heart Study. Circulation 1997;96:308–315.
27.
Franklin SS, Larson MG, Khan SA, Wong ND, Leip EP, Kannel WB, Levy D: Does the relation of blood pressure to coronary heart disease risk change with Aging? The Framingham Heart Study. Circulation 2001;103:1245–1249.
28.
Bots ML, Witteman JC, Hofman A, de Jong PT, Grobbee DE: Low diastolic blood pressure and atherosclerosis in elderly subjects. The Rotterdam study. Arch Intern Med 1996;156:843–848.
29.
Liao D, Arnett DK, Tyroler HA, Riley WA, Chambless LE, Szklo M, Heiss G: Arterial stiffness and the development of hypertension. The ARIC study. Hypertension 1999;34:201–206.
30.
Franklin SS, Khan SA, Wong ND, Larson MG, Levy D: Is pulse pressure useful in predicting risk for coronary heart disease? The Framingham heart study. Circulation 1999;100:354–360.
31.
Chae CU, Pfeffer MA, Glynn RJ, Mitchell GF, Taylor JO, Hennekens CH: Increased pulse pressure and risk of heart failure in the elderly. JAMA 1999;281:634–639.
32.
Gasowski J, Fagard RH, Staessen JA, Grodzicki T, Pocock S, Boutitie F, Gueyffier F, Boissel JP: Pulsatile blood pressure component as predictor of mortality in hypertension: A meta-analysis of clinical trial control groups. J Hypertens 2002;20:145–151.
33.
Blacher J, Staessen JA, Girerd X, Gasowski J, Thijs L, Liu L, Wang JG, Fagard RH, Safar ME: Pulse pressure not mean pressure determines cardiovascular risk in older hypertensive patients. Arch Intern Med 2000;160:1085–1089.
34.
Franklin SS, Sutton-Tyrrell K, Belle SH, Weber MA, Kuller LH: The importance of pulsatile components of hypertension in predicting carotid stenosis in older adults. J Hypertens 1997;15:1143–1150.
35.
Liao D, Cooper L, Cai J, Toole J, Bryan N, Burke G, Shahar E, Nieto J, Mosley T, Heiss G: The prevalence and severity of white matter lesions, their relationship with age, ethnicity, gender, and cardiovascular disease risk factors: the ARIC Study. Neuroepidemiology 1997;16:149–162.
36.
Domanski MJ, Davis BR, Pfeffer MA, Kastantin M, Mitchell GF: Isolated systolic hypertension: Prognostic information provided by pulse pressure. Hypertension 1999;34:3753–3780.
37.
Vaccarino V, Berger AK, Abramson J, Black HR, Setaro JF, Davey JA, Krumholz HM: Pulse pressure and risk of cardiovascular events in the systolic hypertension in the elderly program. Am J Cardiol 2001;88:980–986.
38.
Mazza A, Pessina AC, Pavei A, Scarpa R, Tikhonoff V, Casiglia E: Predictors of stroke mortality in elderly people from the general population. The Cardiovascular Study in the Elderly. Eur J Epidemiol 2001;17:1097–1104.
39.
Staessen JA, Thijs L, O’Brien ET, Bulpitt CJ, de Leeuw PW, Fagard RH, Nachev C, Palatini P, Parati G, Tuomilehto J, Webster J, Safar ME: Ambulatory pulse pressure as predictor of outcome in older patients with systolic hypertension. Am J Hypertens 2002;15:835–843.
40.
Korv J, Roose M, Kaasik AE: Stroke registry of Tartu, Estonia, from 1991 through 1993. Cerebrovasc Dis 1997;7:154–162.
41.
Sacco SE, Whisnant JP, Broderick JP, Phillips SJ, O’Fallon WM: Epidemiological characteristics of lacunar infarcts in a population. Stroke 1991;22:1236–1241.
42.
Safar ME, van Bortel LM, Struijker-Boudier HA: Resistance and conduit arteries following converting enzyme inhibition in hypertension. J Vasc Res 1997;34:67–81.
43.
Heesen WF, Beltman FW, Smit AJ, May JF, de Graeff PA, Havinga TK, Schuurman FH, van der Veur E, Meyboom-de Jong B, Lie KI: Effect of quinapril and triamterene/hydrochlorothiazide on cardiac and vascular end-organ damage in isolated systolic hypertension. J Cardiovasc Pharmacol 1998;31:187–194.
44.
Post-stroke antihypertensive treatment study. A preliminary result. PATS Collaborating Group. Chin Med J 1995;108:710–717.
45.
PROGRESS Collaborative Group. Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6,105 individuals with previous stroke or transient ischaemic attack. Lancet 2001;358:1033–1041.
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