Circulation, Vol 90, 1657-1661, Copyright © 1994 by American Heart Association
HP Selker, JR Beshansky, CH Schmid, JL Griffith, WT Longstreth Jr, CM O'Connor, LR Caplan, EW Massey, RB D'Agostino and MM Laks
BACKGROUND: In selecting patients with acute myocardial infarction for
thrombolytic therapy, it is important to identify patients who are at high
risk for intracranial hemorrhage, for whom thrombolytic therapy is ill
advised. We hypothesized that presenting pulse blood pressure, representing
the "hammer" effect on cerebral vessels and the effects of age on arterial
compliance, might predict thrombolysis-related intracranial hemorrhage
better than systolic, diastolic, or mean arterial blood pressures. METHODS
AND RESULTS: Of 3483 Thrombolytic Predictive Instrument (TPI) Project
subjects receiving thrombolytic therapy for acute infarction, we identified
and obtained detailed clinical data on the 19 with treatment-related
intracranial hemorrhages confirmed by computed tomography and on 175
matched controls. Systolic, diastolic, mean arterial, and pulse blood
pressures were each significantly related to the occurrence of intracranial
hemorrhage, with pulse pressure most highly related. The mean pulse
pressure in patients who developed intracranial hemorrhage was 63 mm Hg,
34% higher than the 47 mm Hg mean value for those not developing hemorrhage
(P = .0001). Excess pulse pressure, defined as the extent to which a
patient's pulse pressure exceeded 40 mm Hg for systolic blood pressures of
at least 120 mm Hg, was even more strongly related: its mean value of 23 mm
Hg for patients was 130% higher than its mean value of 10 mm Hg for
controls (P < .0001). With logistic regression models to estimate the
relative risks (odds ratios) for intracranial hemorrhage conferred by each
form of blood pressure, the relative risk for hemorrhage was greatest for
excess pulse pressure: for each 10-point pulse pressure excess, the
relative risk for intracranial hemorrhage was increased by 1.85 (P = .0002;
95% confidence interval [CI], 1.34 to 2.55) by itself and 1.76 (P = .001;
95% CI, 1.26 to 2.46) when adjusted for age. In this sample, excess pulse
pressure by itself predicted hemorrhage as well as systolic pressure and
age together. When excess pulse pressure was combined with age to make a
logistic regression model predicting intracranial hemorrhage, age
contributed less to the prediction than when combined with the other blood
pressure forms, even though this model predicted better than any other
combination of age and pressure (receiver-operating characteristic curve
area, 0.82 versus 0.77 with systolic pressure and age, 0.75 with mean
arterial pressure, 0.71 with diastolic pressure, and 0.81 with both
systolic and diastolic pressures). CONCLUSIONS: We found that excess pulse
blood pressure predicted thrombolysis-related intracranial hemorrhage
better than other forms of pretreatment blood pressure, perhaps better
describing the pathophysiology of intracranial hemorrhage, including the
effect of age. These findings will need confirmation in larger studies with
comparable clinical detail.
ARTICLES
Presenting pulse pressure predicts thrombolytic therapy-related intracranial hemorrhage. Thrombolytic Predictive Instrument (TPI) Project results
Department of Medicine, New England Medical Center, Boston, MA 02111.
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