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Presenting pulse pressure predicts thrombolytic therapy-related intracranial hemorrhage. Thrombolytic Predictive
H P Selker1, J R Beshansky, C H Schmid
1Department of Medicine, New England Medical Center, Boston, MA 02111.
Insights
Excess pulse pressure, a measure of blood flow impact on cerebral vessels, better predicts intracranial hemorrhage risk in patients receiving thrombolytic therapy than other blood pressure metrics. This finding may improve patient selection for acute myocardial infarction treatment.
Area of Science:
- Cardiology
- Neurology
- Medical Diagnostics
Background:
- Identifying patients at high risk for intracranial hemorrhage is crucial for selecting appropriate thrombolytic therapy in acute myocardial infarction.
- Traditional blood pressure measurements may not fully capture the risk of intracranial hemorrhage associated with thrombolysis.
Purpose of the Study:
- To investigate whether pulse blood pressure, specifically excess pulse pressure, is a better predictor of thrombolysis-related intracranial hemorrhage compared to systolic, diastolic, or mean arterial blood pressures.
- To assess the predictive value of excess pulse pressure, considering its relationship with age and arterial compliance.
Main Methods:
- Analysis of data from 3483 subjects in the Thrombolytic Predictive Instrument (TPI) Project who received thrombolytic therapy.
- Detailed clinical data collection and comparison between 19 patients with confirmed intracranial hemorrhage and 175 matched controls.
- Logistic regression models were used to evaluate the relative risks (odds ratios) of intracranial hemorrhage associated with different blood pressure parameters.
Main Results:
- Pulse blood pressure was significantly related to intracranial hemorrhage, with higher mean pulse pressure observed in patients who developed hemorrhage.
- Excess pulse pressure demonstrated a stronger association with intracranial hemorrhage, showing a 130% higher mean value in patients compared to controls.
- Excess pulse pressure alone predicted hemorrhage risk as effectively as systolic pressure and age combined, and logistic regression models incorporating excess pulse pressure and age yielded the best predictive performance (ROC area 0.82).
Conclusions:
- Excess pulse blood pressure is a superior predictor of thrombolysis-related intracranial hemorrhage compared to other pretreatment blood pressure measurements.
- Excess pulse pressure may better reflect the underlying pathophysiology of intracranial hemorrhage, including the influence of age.
- Further validation in larger studies is recommended to confirm these findings and refine patient selection for thrombolytic therapy.
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.