Intensive vs Conventional Blood Pressure Lowering After Endovascular Thrombectomy in Acute Ischemic Stroke

Abstract

ImportanceOptimal blood pressure (BP) control after successful reperfusion with endovascular thrombectomy (EVT) for patients with acute ischemic stroke is unclear.ObjectiveTo determine whether intensive BP management during the first 24 hours after successful reperfusion leads to better clinical outcomes than conventional BP management in patients who underwent EVT.Design, Setting, and ParticipantsMulticenter, randomized, open-label trial with a blinded end-point evaluation, conducted across 19 stroke centers in South Korea from June 2020 to November 2022 (final follow-up, March 8, 2023). It included 306 patients with large vessel occlusion acute ischemic stroke treated with EVT and with a modified Thrombolysis in Cerebral Infarction score of 2b or greater (partial or complete reperfusion).InterventionsParticipants were randomly assigned to receive intensive BP management (systolic BP target <140 mm Hg; n = 155) or conventional management (systolic BP target 140-180 mm Hg; n = 150) for 24 hours after enrollment.Main Outcomes and MeasuresThe primary outcome was functional independence at 3 months (modified Rankin Scale score of 0-2). The primary safety outcomes were symptomatic intracerebral hemorrhage within 36 hours and death related to the index stroke within 3 months.ResultsThe trial was terminated early based on the recommendation of the data and safety monitoring board, which noted safety concerns. Among 306 randomized patients, 305 were confirmed eligible and 302 (99.0%) completed the trial (mean age, 73.0 years; 122 women [40.4%]). The intensive management group had a lower proportion achieving functional independence (39.4%) than the conventional management group (54.4%), with a significant risk difference (−15.1% [95% CI, −26.2% to −3.9%]) and adjusted odds ratio (0.56 [95% CI, 0.33-0.96]; P = .03). Rates of symptomatic intracerebral hemorrhage were 9.0% in the intensive group and 8.1% in the conventional group (risk difference, 1.0% [95% CI, −5.3% to 7.3%]; adjusted odds ratio, 1.10 [95% CI, 0.48-2.53]; P = .82). Death related to the index stroke within 3 months occurred in 7.7% of the intensive group and 5.4% of the conventional group (risk difference, 2.3% [95% CI, −3.3% to 7.9%]; adjusted odds ratio, 1.73 [95% CI, 0.61-4.92]; P = .31).Conclusions and RelevanceAmong patients who achieved successful reperfusion with EVT for acute ischemic stroke with large vessel occlusion, intensive BP management for 24 hours led to a lower likelihood of functional independence at 3 months compared with conventional BP management. These results suggest that intensive BP management should be avoided after successful EVT in acute ischemic stroke.Trial RegistrationClinicalTrials.gov Identifier: NCT04205305

Intensive vs Conventional Blood Pressure Control After Thrombectomy in Acute Ischemic Stroke

“…During the title and abstract screening phase, 190 records were excluded, leaving 4 records that underwent a full-text article assessment to ascertain eligibility. None of the full-text articles failed to meet the inclusion criteria, resulting in the inclusion of all 4 studies in our quantitative synthesis . The studies were published between 2021 and 2023 and were conducted in China, France, South Korea, and the US.…”

“…A compilation of the 4 studies included in our analysis, along with their respective evaluations of bias across various domains using the RoB 2, can be accessed in eFigures 1 and 2 in Supplement 1. Among these studies, our assessment revealed that 3 of them had a moderate risk of bias, while one was categorized as having a low risk of bias. Notably, the domains demonstrating more concerns were bias arising from the randomization process and bias in measurement of the outcome.…”

“…Rates of functional independence (mRS scores 0-2) between intensive and conventional BP control among 1491 patients were compared across all 4 studies included . The rate of 90-day mRS scores of 0 to 2 in the intensive BP control group (337 of 748 [45.1%]) was observed to be lower compared with the conventional BP control group (415 of 743 [55.9%]), resulting in a calculated RR of 0.81 (95% CI, 0.67-0.98; P = .04) (Figure 2), indicating a statistically significant difference between both groups.…”

“…The conducted analysis comparing the 90-day mortality rates between patients receiving intensive and conventional BP control included 1495 patients from all 4 studies . In the intensive BP control group, the 90-day mortality was found to be higher (114 of 750 [15.2%]) than in the conventional BP control group (96 of 745 [12.9%]).…”

“…This has led to a trend toward intensive BP lowering after EVT, with an SBP target less than 140 or even less than 120 mm Hg . On the other hand, recently published clinical trials indicate that an overly aggressive reduction of SBP after EVT may have a detrimental effect on functional outcomes while affording no significant reductions in rates of ICH following successful recanalization. Therefore, we performed a systematic review and meta-analysis of RCTs comparing different BP targets after EVT for AIS-LVO.…”