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Blood pressure variability and outcome in acute ischemic and hemorrhagic stroke: a post hoc analysis of the HeadPoST study

Journal of Human Hypertension volume 33, pages 411–418 (2019)Cite this article

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Abstract

The Head Positioning in Acute Stroke Trial (HeadPoST) is a pragmatic, international, cluster crossover randomized trial of 11,093 patients with acute stroke assigned to a lying-flat (0°) or sitting-up (head elevated ≥30°) position. This post hoc analysis aimed to determine the association between blood pressure variability (BPV) and outcomes for patients from a wide range of international clinical settings and how the association was modified by randomized head position. BPV was defined according to the standard criteria, with the key parameter considered the coefficient of variation (CV) of systolic BP (SBP) over 24 h. Outcome was ordinal 90-day Modified Rankin Scale (mRS) score. The association was analyzed by ordinal, logistic regression, hierarchical, mixed models with fixed intervention (lying flat vs. sitting up), and fixed period, random cluster, and random cluster-period, effects. Nine thousand one hundred and fifty six (8324 acute ischemic stroke and 817 intracerebral hemorrhage; mean age 68.1 years; 39.2% women) were included in the analysis. CV of SBP had a significant linear association with unfavorable shift of mRS at 90 days (adjusted odds ratio 1.06, 95% confidence interval 1.02–1.11; P = 0.01). There was no heterogeneity of the association by randomized head positioning. In addition, CV of diastolic BP (DBP) (1.08, 1.03–1.12; P = 0.001) over 24 h post stroke was significantly associated with 3-month poor outcome. The association was more apparent in sitting-up position (1.12, 1.06–1.19) compared with lying-flat position (1.03, 0.98–1.09) (P interaction = 0.005). BPV was associated with adverse stroke outcome, and the magnitude of the association was greater with sitting-up head positioning in terms of DBP variability.

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Acknowledgements

Funding

The study is supported by a research grant (1066966) from the National Health and Medical Research Council of Australia.

Author information

Author notes

  1. These authors contributed equally: Jatinder S Minhas, Xia Wang

Authors and Affiliations

  1. Department of Cardiovascular Science, University of Leicester, Leicester, UK

    Jatinder S. Minhas & Thompson G. Robinson

  2. The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia

    Xia Wang, Tom J. Moullaali, Laurent Billot, Maree L. Hackett, John Chalmers & Craig S. Anderson

  3. Department of Neurology and Psychiatry, Clínica Alemana de Santiago, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo and Departamento de Ciencias Neurológicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile

    Pablo M. Lavados & Veronica V. Olavarria

  4. Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK

    Tom J. Moullaali & Gillian E. Mead

  5. Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan

    Hisatomi Arima

  6. Faculty of Health and Wellbeing, The University of Central Lancashire, Preston, UK

    Maree L. Hackett & Caroline Watkins

  7. Nursing Research Institute, Australian Catholic University and St Vincent’s Health Australia, Sydney, NSW, Australia

    Sandy Middleton

  8. Ribeirão Preto Medical School, Univesity of São Paulo, Ribeirão Preto, Brazil

    Octavio Pontes-Neto

  9. Clinical Trials Unit, Department of Pharmacology, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka

    H. Asita De Silva

  10. Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, Taiwan

    Tsong-Hai Lee

  11. Christian Medical College, Ludhiana, Punjab, India

    Jeyaraj D. Pandian

  12. Neurology Department, Royal Prince Alfred Hospital, Sydney, NSW, Australia

    Craig S. Anderson

  13. The George Institute China at Peking University Health Sciences Center, Beijing, China

    Craig S. Anderson

  14. National Institute for Health Research Leicester Biomedical Research Centre, Leicester, UK

    Thompson G. Robinson

Authors
  1. Jatinder S. Minhas
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  2. Xia Wang
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  3. Pablo M. Lavados
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  4. Tom J. Moullaali
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  5. Hisatomi Arima
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  6. Laurent Billot
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  7. Maree L. Hackett
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  8. Veronica V. Olavarria
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  9. Sandy Middleton
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  10. Octavio Pontes-Neto
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  11. H. Asita De Silva
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  13. Jeyaraj D. Pandian
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  14. Gillian E. Mead
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  15. Caroline Watkins
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  16. John Chalmers
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  17. Craig S. Anderson
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  18. Thompson G. Robinson
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Consortia

on behalf of the HeadPoST Investigators

Corresponding author

Correspondence to Craig S. Anderson.

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Conflict of interest

JSM: Dunhill Medical Trust Research Training Fellow (RTF97/0117). PML: Research grants from The George Institute for Global Health, grants from Clínica Alemana de Santiago, during the conduct of the study; non-financial support from Boehringer Ingelheim, grants and personal fees from Bayer, grants and personal fees from Astra Zeneca, grants from CONICYT, outside the submitted work. TJM: British Heart Foundation Clinical Research Training Fellow. HA: Lecture fees from Bayer, Daiichi-Sankyo and Takeda. MLH: NHMRC Career Development Fellowship Level 2 APP 1141328. OMPN: Research grants from CNPq and Brazilian Ministry of Health. THL: Research grant from MOST, BMRP and CMRP, Taiwan. CSA: Advisory Panel fees from Astra Zeneca and Amgen, speaking at seminars for Takeda China; research grant from Takeda China. TGR: NIHR Senior Investigator. The authors declare that they have no conflict of interest.

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Trial registration: clinicaltrials.gov (NCT02162017)

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Minhas, J.S., Wang, X., Lavados, P.M. et al. Blood pressure variability and outcome in acute ischemic and hemorrhagic stroke: a post hoc analysis of the HeadPoST study. J Hum Hypertens 33, 411–418 (2019). https://doi.org/10.1038/s41371-019-0193-z

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