• Lars Kellert, Christian Hametner, Niaz Ahmed, Geraldine Rauch, Mary J MacLeod, Francesco Perini, Kennedy R Lees, Peter A Ringleb, and SITS Investigators.
• From the Department of Neurology, Klinikum der Universität München, Ludwig-Maximilians-University, Germany (L.K.); Department of Neurology, University of Heidelberg (L.K., C.H., P.A.R.) and Institute of Medical Biometry and Informatics (G.R.), University of Heidelberg, Germany; Department of Clinical Neuroscience, Karolinska Institute and Department of Neurology, Karolinska University Hospital, Stockholm, Sweden (N.A.); Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Germany (G.R.); Division of Applied Medicine, University of Aberdeen, Foresterhill, United Kingdom (M.J.M.); Department of Neurology, St. Bortolo Hospital, Vicenza, Italy (F.P.); and Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (K.R.L.). Lars.Kellert@med.uni-muenchen.de.
• Stroke. 2017 Jul 1; 48 (7): 1827-1834.

Background And PurposeSignificance and management of blood pressure (BP) changes in acute stroke care are unclear. Here, we aimed to investigate the impact of 24-hour BP variability (BPV) on outcome in patients with acute ischemic stroke treated with intravenous thrombolysis.MethodsFrom the Safe Implementation of Treatment in Stroke International Stroke Thrombolysis registry, 28 976 patients with documented pre-treatment systolic BP at 2 and 24 hours were analyzed. The primary measure of BP variability was successive variability. Data were preprocessed using coarsened exact matching. We assessed early neurological improvement, symptomatic intracerebral hemorrhage (SICH), and long-term functional outcome (modified Rankin Scale [mRS] at 90 days) by binary and ordinal regression analyses.ResultsAttempts to explain successive variation for analysis of BPV with patients characteristics at admission found systolic BP (5.5% variance) to be most influential, yet 92% of BPV variance remained unexplained. Independently from systolic BP, successive variation for analysis of BPV was associated with poor functional outcome mRS score of 0 to 2 (odds ratio [OR], 0.94; 95% confidence interval [CI], 0.90-0.98), disadvantage across the shift of mRS (OR, 1.04; 95% CI, 1.01-1.08), mortality (OR, 1.10; 95% CI, 1.01-1.08), SICHSITS (OR, 1.14; 95% CI, 1.06-1.23), and SICHECASS (OR, 1.24; 95% CI, 1.10-1.40; ECASS [European Cooperative Acute Stroke Study 2]). Analyzing successive variation for analysis of BPV as a function of pre-treatment, systolic BP significantly improved the prediction of functional outcome (mRS score of 0-1, mRS score of 0-2, neurological improvement, mRS-shift: all Pinteraction<0.01). Excluding patients with atrial fibrillation in a sensitivity analysis gave consistent results overall.ConclusionsThis study suggests the need for a more individual BP management accounting for pre-treatment BP and the acute BP course (ie, BPV) to achieve best possible outcome for the patient.© 2017 American Heart Association, Inc.

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