Association of Elevated Blood Pressure Levels with Outcomes in Acute Ischemic Stroke Patients Treated with Intravenous Thrombolysis: A Systematic Review and Meta-Analysis

Abstract

Background and PurposeAlthough arbitrary blood pressure (BP) thresholds exist for acute ischemic stroke (AIS) patients eligible for intravenous thrombolysis (IVT), current international recommendations lack clarity on the impact of mean pre- and post-IVT BP levels on clinical outcomes. MethodsEligible studies involving IVT-treated AIS patients were identified that reported the association of mean systolic BP (SBP) or diastolic BP levels before and after IVT with the following outcomes: 3-month favorable functional outcome (modified Rankin Scale [mRS] scores of 0–1) and 3-month functional independence (mRS scores of 0–2), 3-month mortality and symptomatic intracranial hemorrhage (sICH). Unadjusted analyses of standardized mean differences and adjusted analyses of studies reporting odds ratios (ORadj) per 10 mm Hg BP increment were performed using random-effects models. ResultsWe identified 26 studies comprising 56,513 patients. Higher pre- (P=0.02) and posttreatment (P=0.006) SBP levels were observed in patients with sICH. Patients with 3-month functional independence had lower post-treatment (P<0.001) SBP whereas trended towards lower pre-treatment (P=0.06) SBP. In adjusted analyses, elevated pre- (ORadj, 1.08; 95% confidence interval [CI], 1.01 to 1.16) and post-treatment (ORadj, 1.13; 95% CI, 1.01 to 1.25) SBP levels were associated with increased likelihood of sICH. Increasing pre- (ORadj, 0.91; 95% CI, 0.84 to 0.98) and post-treatment (ORadj, 0.70; 95% CI, 0.57 to 0.87) SBP values were also related to lower odds of 3-month functional independence. ConclusionsWe found that elevated BP levels adversely impact AIS outcomes in patients receiving IVT. Future randomized-controlled clinical trials will provide definitive data on the aforementioned association.

Effect of blood pressure parameters on functional independence in patients with acute ischemic stroke in the first 6 hours after endovascular thrombectomy

“…Recently, several studies have suggested a significant correlation between BP values in the first 24 hours after EVT and long-term functional outcomes 2–5. Similar to previous studies on acute stage BP and the functional outcomes of patients with AIS receiving intravenous recombinant tissue plasminogen activator (rt-PA), higher BP levels and larger BP variability have been reported to be inversely correlated with functional outcomes in patients with AIS receiving EVT 6 7…”

Prognostic significance of early systolic blood pressure variability after endovascular thrombectomy and intravenous thrombolysis in acute ischemic stroke: A systematic review and meta‐analysis

“…The present study showed no significant associations were indicated between early SBPV after IVT and functional outcome, sICH in AIS. A recent study reported that lower pretreatment and post‐treatment SBP levels were associated with better 3‐month functional outcomes in AIS (Malhotra et al., 2019). The present study focused on the association between BPV after IVT and functional outcome in AIS.…”

Association of maximal systolic blood pressure with poor outcome in patients with hyperattenuated lesions on immediate NCCT after mechanical thrombectomy

“…In fact, in substudies of the Echoplanar Imaging Thrombolytic Evaluation Trial (EPITHET) and ECASS-II, high BP parameters were associated with an increased risk of PH in patients treated with recombinant tissue plasminogen activator 19 20. A recent meta-analysis showed that higher post-treatment SBP levels were associated with a poorer outcome in patients treated with intravenous thrombolysis 21. Another study showed that high SBP max levels following MT were independently associated with an increased likelihood of 3-month mortality and functional dependence 3.…”