高血压是急性卒中的预后因素，但血压变异性可能也是预后的独立预测因素。近期发表于《柳叶刀·神经病学》的一项研究评估了来自INTERACT2研究中受试者血压变异性的预后价值。结果表明，收缩压变异性似乎可预测急性脑出血患者的预后不佳。顺利降低收缩压达140 mm Hg并维持这个水平可提高早期治疗患者的益处，尤其是避免收缩压达到峰值。

        INTERACT2研究纳入了2839例自发脑出血(ICH)的高血压(收缩压150–220 mm Hg)成人患者，这些患者均无明确早期强化降压治疗的适应证或禁忌症。受试者被随机分为强化治疗组(局部静脉注射药物方法使收缩压1小时内降至<140 mm Hg)和指南推荐治疗组(ICH起病6小时内收缩压靶标<180 mm Hg)。主要终点为90天时死亡或严重残疾(改良Rankin量表得分≥3)，次要终点为90天时改良Rankin量表评分的有序转变。根据标准原则定义血压变异性：在超急性期和急性期测定5项指标。评估血压变异性和预后的关系，血压变异性的参数为被分为五分位数收缩压的标准差(SD)。

        结果显示，纳入的超急性期和急性期受试者分别为2645 例(93.2%)和2347例(82.7%)。在两个治疗联合队列中，收缩压的SD与超急性期(最高五分位校正比值比为1.41)和急性期(最高五分位校正比值比为1.57)患者的主要终点呈显著的线性相关关系。预后的最强预测因素为超急性期收缩压达最高和急性期收缩压的SD。类似的相关性也见于次要终点分析中(超急性期最高五分位校正比值比为1.43，急性期为1.46)。

        参考文献：Lisa Manning, et al. The Lancet neurology 2014 Apr;13(4):364-73. doi: 10.1016/S1474-4422(14)70018-3.

Blood pressure variability and outcome after acute intracerebral haemorrhage: a post-hoc analysis of INTERACT2, a randomised controlled trial
Lisa Manning, MBChB, Yoichiro Hirakawa, MD, Hisatomi Arima, PhD, Xia Wang, MMedc, Prof John Chalmers, MD, Prof Jiguang Wang, PhD, Prof Richard Lindley, MD, Emma Heeley, PhD, Candice Delcourt, MD, Prof Bruce Neal, MD, Prof Pablo Lavados, MD, Prof Stephen M Davis, MD, Prof Christophe Tzourio, MD, Prof Yining Huang, MD, Prof Christian Stapf, MD, Prof Mark Woodward, PhD, Prof Peter M Rothwell, FMedScip, Prof Thompson G Robinson, MD, Prof Craig S Anderson, MD
Background
High blood pressure is a prognostic factor for acute stroke, but blood pressure variability might also independently predict outcome. We assessed the prognostic value of blood pressure variability in participants of INTERACT2, an open-label randomised controlled trial (ClinicalTrials.gov number NCT00716079).
Methods
INTERACT2 enrolled 2839 adults with spontaneous intracerebral haemorrhage (ICH) and high systolic blood pressure (150–220 mm Hg) without a definite indication or contraindication to early intensive treatment to reduce blood pressure. Participants were randomly assigned to intensive treatment (target systolic blood pressure <140 mm Hg within 1 h using locally available intravenous drugs) or guideline-recommended treatment (target systolic blood pressure <180 mm Hg) within 6 h of onset of ICH. The primary outcome was death or major disability at 90 days (modified Rankin Scale score ≥3) and the secondary outcome was an ordinal shift in modified Rankin Scale scores at 90 days, assessed by investigators masked to treatment allocation. Blood pressure variability was defined according to standard criteria: five measurements were taken in the first 24 h (hyperacute phase) and 12 over days 2–7 (acute phase). We estimated associations between blood pressure variability and outcomes with logistic and proportional odds regression models. The key parameter for blood pressure variability was standard deviation (SD) of systolic blood pressure, categorised into quintiles.
Findings
We studied 2645 (93•2%) participants in the hyperacute phase and 2347 (82•7%) in the acute phase. In both treatment cohorts combined, SD of systolic blood pressure had a significant linear association with the primary outcome for both the hyperacute phase (highest quintile adjusted OR 1•41, 95% CI 1•05–1•90; ptrend=0•0167) and the acute phase (highest quintile adjusted OR 1•57, 95% CI 1•14–2•17; ptrend=0•0124). The strongest predictors of outcome were maximum systolic blood pressure in the hyperacute phase and SD of systolic blood pressure in the acute phase. Associations were similar for the secondary outcome (for the hyperacute phase, highest quintile adjusted OR 1•43, 95% CI 1•14–1•80; ptrend=0•0014; for the acute phase OR 1•46, 95% CI 1•13–1•88; ptrend=0•0044).
Interpretation
Systolic blood pressure variability seems to predict a poor outcome in patients with acute intracerebral haemorrhage. The benefits of early treatment to reduce systolic blood pressure to 140 mm Hg might be enhanced by smooth and sustained control, and particularly by avoiding peaks in systolic blood pressure.