Wook-Joo Kim

Blood pressure variability and the development of early neurological deterioration following acute ischemic stroke

Objectives: Early neurological deterioration (END) is a common condition associated with poor outcome after acute ischemic stroke. We studied association between blood pressure (BP) variability and development of END. Methods: In this retrospective observational study, we studied a consecutive series of patients hospitalized for acute ischemic stroke within 24u200ah of onset. The primary outcome of interest was the development of END according to predefined criteria within the first 72u200ah of stroke onset. During this period, the mean, maximum (max), and minimum (min) values for the SBP and DBP were measured. The following parameters of BP variability were calculated for the SBP and DBP: the difference between the maximum and minimum (max−min), the SD, and the coefficient of variation. Results: Of the 1161 patients enrolled in the study (mean age, 67.5u200a±u200a13.3 years; 59.6% men), 210 (18.1%) developed END. All of the BP variability parameters were linearly associated with END independent of mean BP and potential clinical variables (P valuesu200a<u200a0.05 on likelihood ratio tests for trend), except for SBPmax−min. Among the other BP parameters, SBPmean, SBPmax, DBPmax, and DBPmin were independently associated with END. After adjustments for potential confounders, the odds for END increased 14–21% with each increase of one standard deviation in the BP variability parameter. Conclusion: BP variability is independently and linearly associated with the development of neurologic deterioration in acute stage of ischemic stroke.

Symptomatic steno-occlusion of cerebral arteries and subsequent ischemic events in patients with acute ischemic stroke

BACKGROUNDnWe aimed to assess the impact of symptomatic steno-occlusion (SYSO) of cerebral arteries and its characteristics on subsequent ischemic event (SIE) in patients with acute ischemic stroke.nnnMETHODSnUsing a prospective stroke registry database, we identified consecutive patients with ischemic stroke who were hospitalized within 48xa0hours of symptom onset. SYSO denoted significant stenosis or occlusion of major cerebral arteries with ischemic lesions at the corresponding arterial territories and was characterized by its location and severity. Primary outcome was SIE that was defined as ischemic progression or recurrence within 1xa0year.nnnRESULTSnIn total, 1546 patients (age, 67.4xa0±xa013.0xa0years; median National Institutes of Health Stroke Scale score, 4) were enrolled in this study. The cumulative risk of SIE was 14.5% at 7xa0days, 14.9% at 14xa0days, 15.5% at 90xa0days, and 16.9% at 1xa0year. Patients with SYSO had significantly higher SIE rates compared with those without SYSO (23.0% versus 11.6%). Of the characteristics of SYSO, the location, not the severity, was significantly associated with SIE (Pxa0<xa0.001 and Pxa0=xa0.186, respectively). Multiple (adjusted hazard ratio, 5.85; 95% confidence interval, 1.81-18.85), intracranial internal carotid artery (ICA) (3.54; 1.21-8.21), and extracranial ICA SYSO (2.88; 1.01-8.21) raised the risk of SIE.nnnCONCLUSIONSnSubsequent cerebral ischemic events (progression or recurrence) after an acute ischemic stroke occur mostly within several days of stroke onset and is associated with the location, but not the severity, of symptomatic steno-occlusion of cerebral arteries.

Association between Left Ventricular Dysfunction and Functional Outcomes at Three Months in Acute Ischemic Stroke

BACKGROUNDnLeft ventricular dysfunction (LVD) was associated with stroke occurrence and mortality. However, few studies have published the impact of LVD on functional stroke outcomes in the acute stroke period.nnnMETHODSnWe enrolled 1554 patients who were admitted to Dong-A University Hospital between January 2011 and November 2014. To determine the functional outcomes, the modified Rankin Scale (mRS) score at 3 months after stroke was used. The severity of LVD was defined depending on ejection fraction (EF): (1) severe (EFu2009≤u200940%); (2) mild (40%u2009<u2009EFu2009<u200955%); and (3) normal (EFu2009≥u200955%). EF was measured using transthoracic two-dimensional echocardiography. The distribution of mRS scores at 3 months after stroke was presented using LVD. Multivariable analysis was performed to predict poor functional outcomes.nnnRESULTSnOf the 1554 patients, 1417 had normal LV function, 87 had mild LVD, and 50 had severe LVD. Patients with LVD were older and had a high incidence of diabetes mellitus, atrial fibrillation, coronary artery disease, and severe stroke symptoms. With respect to treatment, patients with LVD received more thrombolysis and more anticoagulation medication after stroke. Stroke-related disability at discharge and at 3 months was significantly associated with LVD. In the multivariable analyses, old age, diabetes mellitus, high initial National Institutes of Health Stroke Scale score, stroke mechanism, and LVD were independent predictors of poor functional outcomes at 3 months.nnnCONCLUSIONSnLVD is associated with poor functional outcomes after acute ischemic stroke.

Simple Estimates of Symptomatic Intracranial Hemorrhage Risk and Outcome after Intravenous Thrombolysis Using Age and Stroke Severity

Hye Jung Lee, Ji Sung Lee, Jay Chol Choi, Yong-Jin Cho, Beom Joon Kim, Hee-Joon Bae, Dong-Eog Kim, Wi-Sun Ryu, Jae-Kwan Cha, Dae Hyun Kim, Hyun-Wook Nah, Kang-Ho Choi, Joon-Tae Kim, Man-Seok Park, Jeong-Ho Hong, Sung Il Sohn, Kyusik Kang, Jong-Moo Park, Wook-Joo Kim, Jun Lee, Dong-Ick Shin, Min-Ju Yeo, Kyung Bok Lee, Jae Guk Kim, Soo Joo Lee, Byung-Chul Lee, Mi Sun Oh, Kyung-Ho Yu, Tai Hwan Park, Juneyoung Lee, Keun-Sik Hong Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Korea Clinical Research Center, Asan Medical Center, Seoul, Korea Department of Neurology, Jeju National University, Jeju, Korea Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Korea Department of Neurology, Dong-A University College of Medicine, Busan, Korea Department of Neurology, Chonnam National University Medical School and Hospital, Gwangju, Korea Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, Korea Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Korea Department of Neurology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea Department of Neurology, Yeungnam University Hospital, Daegu, Korea Department of Neurology, Chungbuk National University Hospital, Cheongju, Korea Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Korea Department of Neurology, Eulji University Hospital, Daejeon, Korea Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea Department of Neurology, Seoul Medical Center, Seoul, Korea Department of Biostatistics, Korea University College of Medicine, Seoul, Korea

Trajectory Groups of 24-Hour Systolic Blood Pressure After Acute Ischemic Stroke and Recurrent Vascular Events

Background and Purpose— Blood pressure dynamics in patients with acute ischemic stroke may serve as an important modifiable and prognostic factor. Methods— A total of 8376 patients with acute ischemic stroke were studied from a prospective multicenter registry. Patients were eligible if they had been admitted within 24 hours of symptom onset and had ≥5 systolic blood pressure (SBP) measurements during the first 24 hours of hospitalization. SBP trajectory groups in the first 24 hours were identified using the TRAJ procedure in SAS software with delta-Bayesian Information Criterion and prespecified modeling parameters. Vascular events, including recurrent stroke, myocardial infarction, and death, were prospectively collected. The risk of having vascular events was calculated using the frailty model to adjust for clustering by hospital. Results— The group-based trajectory model classified patients with acute ischemic stroke into 5 SBP trajectory groups: low (22.3%), moderate (40.8%), rapidly stabilized (11.9%), acutely elevated (18.5%), and persistently high (6.4%) SBP. The risk of having vascular events was increased in the acutely elevated (hazard ratio, 1.28 [95% confidence interval, 1.12–1.47]) and the persistently high SBP groups (hazard ratio, 1.67 [95% confidence interval, 1.37–2.04]) but not in the rapidly stabilized group (hazard ratio, 1.13 [95% confidence interval, 0.95–1.34]), when compared with the moderate SBP group. Conclusions— SBP during the first 24 hours after acute ischemic stroke may be categorized into distinct trajectory groups, which differ in relation to stroke characteristics and frequency of subsequent recurrent vascular event risks. The findings may help to recognize potential candidates for future blood pressure control trials.

[PP.12.08] EVALUATION OF EFFICACY AND SAFETY OF AMOSARTAN IN PATIENTS WITH ESSENTIAL HYPERTENSION; 2-YEAR, NON-INTERVENTIONAL, MULTICENTER, RETROSPECTIVE OBSERVATIONAL STUDY

Objective: Studies have shown that combination of amlodipine and losartan resulted in significantly greater decrease in BP compared with amlodipine or losartan monotherapy in patients with essential hypertension. Amosartan is the first ARB/CCB (losartan/amlodipine) combination to be made and used in Korea, yet the safety and efficacy of chronic use has not been addressed. The objective of this study was to determine the safety and efficacy of long term Amosartan use in patients with essential hypertension. Design and method: A non-interventional, multicenter, retrospective observational study was conducted on 1000 healthy subjects. Subjects were hypertensive patients administered with Amosartan for at least 2 years with no more than 10 consecutive weeks of withdrawal period, and the duration of Amosartan therapy being more than 80% of the total follow-up period. The change in SBP and DBP 2 years in relation to baseline was analyzed as visit-to-visit BP variability during Amosartan follow-up period. SBP and DBP was measured and charted in each visit. Results: The percentage of patients who reached target SBP and both target SBP and DBP increased with prolonged duration of Amosartan treatment. However, there were reductions in the percentage of patients who reached target DBP at 3 months and 6 months after Amosartan treatment compared to baseline. 90% of total patients reached target SBP at 24 months after Amosartan treatment compared to 51% at baseline. 94% of total patients reached target DBP at 24 months after Amosartan treatment compared to 90% at baseline. 86% of total patients reached both target SBP and DBP at 24 months after Amosartan treatment compared to 45% at baseline. The mean SBP and DBP were consistently lower than the baseline values during the entire follow-up period after Amosartan treatment. The reduction in SBP and DBP in comparison to baseline was greatest at both 18 and 24 months after Amosartan treatment. Conclusions: The results of this study indicate that the long-term administration of Amosartan is effective in reducing and maintaining target blood pressure in patients with essential hypertension.

Novel Parameter Indicating the Arterial Compliance Indirectly Obtained by Decoupling Ambulatory Arterial Stiffness Index: Pp.2.77:

Objective: Arterial stiffness usually represented by the compliance is one of the important parameters indicating the healthiness of the arteries. But the direct measurement of the arterial compliance is often not practical and the pulse wave velocity (PWV) would be measured instead. Measuring PWV needs some specialized equipment and lacks the extended monitoring. Meanwhile it was proposed that by measuring the usual systolic and diastolic blood pressures for around 24 hours with the interval of about half an hour a parameter may be derived that is related with the arterial stiffness. This is called an ambulatory arterial stiffness index (AASI). Even with fair amount of success, AASI has been criticized to be a coupled parameter showing a ventriculo-arterial coupling factor. Here the decoupling is attempted. Design and Method: Various types of the pulse wave velocities are measured along with the 24 hour ambulatory blood pressure monitoring (ABPM) for the patients with hypertension. AASI is obtained following the definition using the ABPM data. A model of the blood pressure change at a point in arteries is proposed and a decoupled parameter(λ) reflecting the characteristic time of arteries relaxation is extracted from the ABPM data. This parameter may represent indirectly the arterial compliance. Results and Conclusions: Three separately obtained results of PWV, AASI and our proposed parameter are compared. Brachial-ankle, heart-carotid and heart-femoral PWVs show the correlation coefficients of 0.437, 0.314 and 0.541, respectively, with λ and of 0.423, 0.241 and 0.321, respectively with AASI. Because the aim of the decoupling is to do away with the influence from the heartbeat interval, it would be informative to look into the PWVs related with the heart itself. We show that our parameter(λ) is better correlated with PWV than AASI is. Figure 1. No caption available.