摘要目的 探讨积极降压与指南推荐的标准血压控制对缺血性卒中患者静脉重组组织型纤溶原酶激活剂(recombinant tissue plasminogen activator,rtPA)溶栓后早期再灌注及转归的影响.方法 前瞻性纳入50例收缩压在150 ～ 185 mmHg(1 mmHg=0.133 kPa)之间并接受rtPA静脉溶栓治疗的急性缺血性卒中患者,随机分为积极降压组和指南降压组,每组25例.积极降压组在60 min内将血压降至收缩压140 ～150mmHg并至少维持72 h);指南降压组按指南推荐将收缩压降至目标值＜180 mmHg.在溶栓前和溶栓后24 h进行多模式MRI检查.主要终点指标为90 d改良Rankin量表(modified Rankin Scale,mRS)评分及90 d病死率,次要终点指标为缺血脑组织早期再灌注率、血管再通率以及有症状颅内出血发生率.结果 两组人口统计学和基线资料均无统计学差异.积极降压组溶栓后24 h、48 h和72 h内的收缩压水平均显著低于指南降压组,而舒张压则无统计学差异.积极降压组90 d转归良好率(mRS评分0～2分:68％对64％;x2=0.089,P=0.765)、病死率(4％对12％;x2=1.087,P=0.297)、有症状颅内出血发生率(4％对8％;x2=0.355,P=0.552)以及溶栓治疗后的再灌注率(76％对68％;x2 =0.397,P=0.529)和血管再通率(56％对52％;x2 =0.081,P=0.777)与指南降压组差异均无统计学.结论 急性缺血性卒中rtPA静脉溶栓患者急性期积极降压对再灌注无不利影响,也不会增高死亡或残疾风险.

abstractsObjective To investigate the effects of intensive antihypertensive treatment and guidelinerecommended standard blood pressure control on early reperfusion and outcomes after intravenous recombinant tissue plasminogen activator (rtPA) thrombolysis in patients with acute ischemic stroke.Methods A total of 50 patients with acute ischemic stroke (systolic blood pressure,150-185 mmHg;1 mmHg=0.133 kPa) and received intravenous rtPA therapy were enrolled prospectively.They were randomly divided into either a intensive antihypertensive treatment group or a guideline antihypertensive treatment group.In the the intensive antihypertensive treatment group,systolic blood pressure was decreased to 140-150 mmHg in 60 min for at least 72 h.In the guideline antihypertensive treatment group,systolic blood pressure was decreased to the target value ＜ 180 mmHg according to the guideline recommendation.Multi-mode MRI was completed at 24 h before and after thrombolysis.The primary endpoints were the modified Rankin Scale (mRS) score at day 90 and the mortality at day 90;the secondary endpoints were the early reperfusion rate in ischemic brain tissue,recanalization rate,and incidence of symptomatic intracranial hemorrhage.Results There was no significant difference in demographics and baseline data between the 2 groups.Within 24,48,and 72 h after thrombolysis the mean systolic blood pressure in the intensive antihypertensive treatment group was significantly lower than those in the guideline antihypertensive treatment group,while there was no significant difference in diastolic blood pressure.There were no significant differences in favorable outcome rate at day 90 (mRS score 0-2:68％ vs.64％;x2 =0-089,P=0.765),mortality (4％ vs.12％;x2 =1.087,P=0.297),incidence of symptomatic intracranial hemorrhage (4％ vs.8％;x2 =0.355,P =0.552),reperfusion rate after thrombolysis (76％ vs.68％;x2 =0.397,P =0.529),and recanalization rate (56％ vs.52％;x2 =0.081,P =0.777) between the intensive antihypertensive treatment group and the guideline antihypertensive treatment group.Conclusions Early intensive antihypertensive treatment in patients with acute ischemic stroke received intravenous rtPA thrombolysis does not have adverse effect on reperfusion rate,and does not increase the risk of death or disability either.