An Association Between Systolic Blood Pressure and Stroke Among Patients With Impaired Consciousness in Out-of-Hospital Emergency Settings

Taro Irisawa; Taku Iwami; Tetsuhisa Kitamura; Chika Nishiyama; Tomohiko Sakai; Kayo Tanigawa-Sugihara; Sumito Hayashida; Tatsuya Nishiuchi; Tadahiko Shiozaki; Osamu Tasaki; Takashi Kawamura; Atsushi Hiraide; Takeshi Shimazu

Disclosures

BMC Emerg Med. 2013;13(24)

Conclusions

Elevated SBP among emergency patients with impaired consciousness in the field was associated with the increased risk of stroke. Additional research is necessary to determine if field diagnosis of stroke with measuring BP improves procession of care or outcome.

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Abbreviations
SBP: Systemic blood pressure; EMS: Emergency medical service; AOR: Adjusted odds ratio; CI: Confidence interval; SAH: Subarachnoid hemorrhage; IS: Ischemic stroke; ICH: Intracranial hemorrhage; JCS: Japan come scale; ELST: Emergency life-saving technician; CIs: Confidence intervals; GCS: Glasgow Come Scale.

Authors' contributions
TI, TI, TK, CN, TS, KT, SH, TN, TS, OT, TK, AH, and TS participated in the idea formation, study design, data analyses, interpretation of results and writing of the report. All the authors read and approved the final manuscript.

Acknowledgments
We are greatly indebted to all of the EMS personnel at the Osaka Municipal Fire Department and concerned physicians in Osaka City for their indispensable cooperation and support.

Table 1. Japan Coma Scale for grading impaired consciousness
Mild disturbance:
The patient is awake without any stimuli, and is
1.	Almost completely conscious,
2.	Unable to recognize time, place and person,
3.	Unable to recall name and date of birth.
Moderate disturbance:
The patient can be aroused
10.	Easily by being spoken to,
	*(responsive with purposeful movements, phrases, or word)
20.	With loud voice or shaking the shoulders,
	*(almost steadily responsive with very simple words-yes or no, or movements)
30.	Only by repeated mechanical stimuli.
Then, the patient falls into the previous state by cessation of stimulation.
Severe disturbance:
The patient cannot be aroused by any forceful mechanical noise stimuli, and
100.	Responds with movements to avoid the stimulus,
200.	Responds with slight movements including decerebrate and decorticate postures,
300.	Does not respond at all except for change in respiratory rhythm.

*Used in patients who cannot open their eyes for any reason.
This table was revised from Reference [5].

Table 2. Characteristics of eligible and non-eligible patients
	Eligible	No eligible	P value
	(N = 106,706)	(N = 21,972)	P value
Men, n (%)	57,879 (54.2)	13,341 (60.7)	<0.001
Age, year, mean (SD)	63.1 (20.7)	62.3 (20.4)	<0.001
> = 75 years, n (%)	37,793 (35.4)	7167 (32.6)	<0.001
Consciousness, n (%)			<0.001
Mild disturbance	75,437 (70.7)	12,573 (57.2)
Moderate disturbance	16,979 (15.9)	2121 (9.7)
Severe disturbance	14,290 (13.4)	7278 (33.1)
Home, n (%)	52,936 (49.6)	10,164 (46.3)	<0.001
SBP, mmHg, mean (SD)	139.5 (36.1)	―
DBP, mmHg, mean (SD)	77.8 (21.1)	―
HR, counts per a minute, mean (SD)	89.0 (22.3)	70.7 (39.9)	<0.001
SpO₂, %, median (IQR)	96 (94–98)	95 (88–98)	<0.001
Call to arrival at the scene, minute, mean (SD)	6.3 (2.5)	6.1 (2.5)	<0.001
Call to contact with patients, minute, mean (SD)	7.5 (2.7)	7.2 (2.8)	<0.001
Call to hospital arrival, minute, mean (SD)	25.1 (8.6)	22.3 (8.7)	<0.001

SBP denotes systolic blood pressure, DBP diastolic blood pressure, HR heart rate; SD standard deviation, IQR inter-quartile range.

Table 3. Characteristics of patients with impaired consciousness according to prehospital systolic blood pressure
	SBP (mmHg)
	= < 100	101–120	121–140	141–160	161–180	181–200	> = 201
	(N = 14,410)	(N = 22,352)	(N = 23,776)	(N = 19,465)	(N = 12,970)	(N = 7791)	(N = 5942)
Age, year, mean (SD)	64.0 (21.0)	57.2 (22.4)	59.5 (22.3)	65.2 (19.1)	68.7 (15.9)	70.1 (14.1)	69.9 (13.2)
> = 75 years, n (%)	5485 (38.1)	6743 (30.2)	7639 (32.1)	7294 (37.5)	5243 (40.4)	3212 (41.2)	2177 (36.6)
Men, n (%)	7434 (51.6)	11,221 (50.2)	12,962 (54.5)	11,227 (57.7)	7357 (56.7)	4312 (55.3)	3366 (56.6)
Consciousness, n (%)
Mild disturbance	9915 (68.8)	16,547 (74.0)	17,705 (74.5)	14,081 (72.3)	8948 (69.0)	4977 (63.9)	3264 (54.9)
Moderate disturbance	2408 (16.7)	3425 (15.3)	3608 (15.2)	3014 (15.5)	2092 (16.1)	1392 (17.9)	1040 (17.5)
Severe disturbance	2087 (14.5)	2380 (10.6)	2463 (10.4)	2370 (12.2)	1930 (14.9)	1422 (18.3)	1638 (27.6)

SBP denotes systolic blood pressure, SD standard deviation.

Table 4. Proportion of stroke patients with impaired consciousness according to prehospital systolic blood pressure
		SBP (mmHg)
	All	= < 100	101–120	121–140	141–160	161–180	181–200	> = 201
	(N = 106,706)	(N =14,410)	(N =22,352)	(N =23,776)	(N =19,465)	(N =12,970)	(N =7791)	(N =5942)
Stroke, n (%)	33,084 (31.0)	2467 (17.1)	4515 (20.2)	6050 (25.4)	6752 (34.7)	5506 (42.5)	4008 (51.4)	3786 (63.7)
SAH, n (%)	1631 (1.5)	81 (0.6)	124 (0.6)	243 (1.0)	285 (1.5)	270 (2.1)	286 (3.7)	342 (5.8)
ICH, n (%)	6699 (6.3)	228 (1.6)	434 (1.9)	709 (3.0)	1100 (5.7)	1260 (9.7)	1274 (16.4)	1694 (28.5)
IS, n (%)	24,754 (23.2)	2158 (15.0)	3957 (17.7)	5098 (21.4)	5367 (27.6)	3976 (30.7)	2448 (31.4)	1750 (29.5)
No stroke, n (%)	73,622 (69.0)	11,943 (82.9)	17,837 (79.8)	17,726 (74.6)	12,713 (65.3)	7464 (57.5)	3783 (48.6)	2156 (36.3)

SBP denotes systolic blood pressure, SAH subarachnoid hemorrhage, ICH intracranial hemorrhage, IS ischemic stroke.

Table 5. Relationship between prehospital SBP and stroke occurrence by impaired consciousness level
		SBP (mmHg)
		= < 100	101–120	121–140	141–160	161–180	181–200	> = 201
	Mild disturbance	0.70 (0.65–0.75)	Reference	1.30 (1.23–1.38)	1.78 (1.68–1.88)	2.31 (2.17–2.45)	2.98 (2.78–3.20)	4.30 (3.96–4.66)
Stroke	Moderate disturbance	0.66 (0.58–0.75)	Reference	1.29 (1.16–1.44)	2.05 (1.84–2.29)	2.55 (2.26–2.87)	3.57 (3.12–4.08)	6.69 (5.72–7.82)
	Severe disturbance	0.70 (0.61–0.80)	Reference	1.39 (1.23–1.56)	2.03 (1.80–2.29)	2.75 (2.42–3.12)	4.80 (4.15–5.56)	8.21 (7.04–9.56)
	Mild disturbance	0.99 (0.60–1.63)	Reference	2.35 (1.66–3.34)	3.75 (2.64–5.32)	5.91 (4.13–8.45)	8.91 (6.14–12.94)	16.84 (11.71–24.21)
SAH	Moderate disturbance	1.01 (0.50–2.09)	Reference	2.34 (1.36–4.03)	3.59 (2.10–6.15)	5.08 (2.93–8.78)	9.92 (5.81–16.93)	11.55 (6.70–19.90)
	Severe disturbance	0.98 (0.66–1.46)	Reference	1.72 (1.23–2.39)	2.50 (1.81–3.45)	3.12 (2.25–4.32)	5.35 (3.89–7.37)	6.23 (4.58–8.48)
	Mild disturbance	0.74 (0.57–0.96)	Reference	1.76 (1.47–2.10)	3.17 (2.67–3.76)	5.82 (4.91–6.90)	10.90 (9.17–12.94)	21.19 (17.86–25.13)
ICH	Moderate disturbance	0.45 (0.31–0.67)	Reference	1.14 (0.88–1.48)	2.68 (2.11–3.39)	4.64 (3.67–5.87)	7.19 (5.66–9.14)	13.58 (10.71–17.22)
	Severe disturbance	0.88 (0.68–1.13)	Reference	1.62 (1.31–2.01)	2.80 (2.28–3.43)	4.35 (3.55–5.33)	7.34 (5.98–9.00)	12.61 (10.35–15.35)
	Mild disturbance	0.70 (0.65–0.75)	Reference	1.23 (1.16–1.30)	1.59 (1.47–1.65)	1.77 (1.67–1.89)	1.83 (1.70–1.97)	1.75 (1.60–1.90)
IS	Moderate disturbance	0.70 (0.61–0.81)	Reference	1.26 (1.12–1.41)	1.65 (1.47–1.86)	1.63 (1.44–1.85)	1.68 (1.46–1.93)	1.84 (1.58–2.15)
IS	Severe disturbance	0.67 (0.58–0.78)	Reference	1.15 (1.00–1.31)	1.27 (1.12–1.45)	1.26 (1.10–1.44)	1.16 (1.00–1.34)	0.91 (0.78–1.06)

SBP denotes systolic blood pressure, SAH subarachnoid hemorrhage, ICH, intracranial hemorrhage, IS ischemic stroke. Odds ratio were adjusted for sex and age.

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An Association Between Systolic Blood Pressure and Stroke Among Patients With Impaired Consciousness in Out-of-Hospital Emergency Settings

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