Blood Pressure Goals and Clinical Outcomes after Successful Endovascular Therapy: A Multicenter Study

Anadani, Mohammad; Arthur, Adam S; Tsivgoulis, Georgios; Simpson, Kit N.; Alawieh, Ali; Orabi, Yser; Goyal, Nitin; Alexandrov, Andrei V.; Maier, Ilko; Psychogios, Marios; Liman, Jan; Brinton, Daniel; Swisher, Christa B.; Shah, S.P.; Inamullah, Ovais; Keyrouz, Salah; Kansagra, Akash P.; Allen, Michelle; Giles, James A; Wolfe, Stacey Quintero; Fargen, Kyle M; Gory, Benjamin; Marini, Pierre De; Kan, Peter; Nascimento, Fábio A.; Almallouhi, Eyad; Petersen, Nils; Kodali, Sreeja; Rahman, Shareena; Richard, Sébastien; Spiotta, Alejandro M

doi:10.1002/ana.25716

Cited by 57 publications

(77 citation statements)

References 30 publications

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“…Indeed, mTICI 2B patients could be a population at risk and more prone to infarct growth in case of BP variability. Of note, three studies evaluated the reperfusion status with the mTICI score (6,13,30), but the other two studies assessed the reperfusion with the TICI score (11,16). This difference could have had an impact on the grading of TICI 2 patients (some mTICI 2B, successfully reperfused patients being classified as TICI 2A in case of >50% but less than two-thirds) and could have influenced the studied associations.…”

Section: Discussionmentioning

confidence: 99%

“…Of note, no steady BP parameters were associated with sICH in studies with BP control after successful EVT. Interestingly, sICH occurred in 3, 8, 5% in the intensive BP control group (SBP < 140 mmHg), moderate BP control group (SBP < 160 mmHg) and guideline-recommended group (SBP < 180 mmHg) and there was no significant association between these BP goals and the odds of sICH (30).…”

Section: Studies With Specific Post-evt Bp Targetsmentioning

confidence: 91%

“…As illustrated in the flow chart ( Figure 1) and in the Supplementary Methods, 18 studies evaluated BP impact after EVT ( Supplementary Table 2) (6, 7, 9, 11, 13-19, 21-25, 29, 30). Among them, 5 studies were specifically designed to assess BP impact after successful reperfusion and were included for the present systematic review ( Table 1, details in Supplementary Table 3) (6,11,13,16,30). All studies were retrospective, and four were multicentric.…”

Section: Study Selection and Descriptionmentioning

confidence: 99%

“…Modality of BP Assessment, BP Targets and BP Variability After EVT BP was monitored non-invasively after EVT in three studies, (6,11,16) both invasively and non-invasively according to the center in one study (30) and not mentioned in one study (13) ( Table 1). Three studies proposed a BP target after EVT (11,16,30). Among them, one study proposed three BP targets: an intensive BP control (SBP < 140 mmHg), a moderate (SBP < 160 mmHg) and guideline-recommended BP control (SBP < 180 Table 1.…”

Section: Hemodynamic Parameters and Treatmentsmentioning

confidence: 99%

“…Among the three studies with specific post-EVT BP targets, two specifically assessed BP parameters with functional outcome after successful EVT (16,30). In these studies, steady BP parameters consisted of an intensive BP control (SBP < 140 mmHg), which was associated with higher odds of good functional outcome compared with guideline-recommended BP targets (SBP < 180 mmHg) (30), while mean SBP > 130 mmHg (OR = 2.66 [1.11-6.41]) (16) was associated with poor outcome, Table 2. No dynamic parameters (BP variability) were evaluated in these studies with strict post-EVT BP targets.…”

Section: Studies With Specific Post-evt Bp Targetsmentioning

confidence: 99%

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Impact of Blood Pressure After Successful Endovascular Therapy for Anterior Acute Ischemic Stroke: A Systematic Review

et al. 2020

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Background and Purpose: Optimal blood pressure (BP) targets after endovascular therapy (EVT) for acute ischemic stroke (AIS) still need to be assessed, especially according to the recanalization status. Facing the lack of randomized controlled trials addressing this question, we performed a systematic review of studies assessing the post-EVT BP impact on functional outcome and symptomatic intracranial hemorrhage (sICH). Methods: Studies published after January 1, 2012 were included in the systematic review. The PRISMA checklist and flow diagram were followed for the design and reporting of this work. Results: Five studies were included in the present analysis. Despite a significant heterogeneity among studies which precluded a meta-analysis, systolic BP (SBP) was the most frequently used parameter to describe BP. BP variability (standard deviation, successive variability) after EVT was associated with worse functional outcome, especially in studies without specific BP targets after successful EVT. Lower BP values after successful EVT were associated with lower odds of sICH. Four studies evaluated the post-EVT BP impact on recanalized patients solely, with only one specifically addressing the impact of a TICI 2B vs. 2C. Interestingly, SBP reduction was inversely associated with worse outcomes in TICI 3 patients but not in TICI 2B patients, pointing to the potential value of BP management according to the exact TICI. Conclusions: BP post-EVT seems to be associated with worse functional outcomes and sICH. However, given the important heterogeneity depicted among the included studies, no decisive conclusion can be made from this systematic review, thus underlying the urgent need of randomized controlled trials evaluating this question.

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Section: Discussionmentioning

confidence: 99%

Section: Studies With Specific Post-evt Bp Targetsmentioning

confidence: 91%

Section: Study Selection and Descriptionmentioning

confidence: 99%

Section: Hemodynamic Parameters and Treatmentsmentioning

confidence: 99%

Section: Studies With Specific Post-evt Bp Targetsmentioning

confidence: 99%

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Impact of Blood Pressure After Successful Endovascular Therapy for Anterior Acute Ischemic Stroke: A Systematic Review

et al. 2020

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Blood Pressure Management After Endovascular Therapy for Acute Ischemic Stroke

Mistry,

Hart,

Davis

et al. 2023

JAMA

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ImportanceThe effects of moderate systolic blood pressure (SBP) lowering after successful recanalization with endovascular therapy for acute ischemic stroke are uncertain.ObjectiveTo determine the futility of lower SBP targets after endovascular therapy (&lt;140 mm Hg or 160 mm Hg) compared with a higher target (≤180 mm Hg).Design, Setting, and ParticipantsRandomized, open-label, blinded end point, phase 2, futility clinical trial that enrolled 120 patients with acute ischemic stroke who had undergone successful endovascular therapy at 3 US comprehensive stroke centers from January 2020 to March 2022 (final follow-up, June 2022).InterventionAfter undergoing endovascular therapy, participants were randomized to 1 of 3 SBP targets: 40 to less than 140 mm Hg, 40 to less than 160 mm Hg, and 40 to 180 mm Hg or less (guideline recommended) group, initiated within 60 minutes of recanalization and maintained for 24 hours.Main Outcomes and MeasuresPrespecified multiple primary outcomes for the primary futility analysis were follow-up infarct volume measured at 36 (±12) hours and utility-weighted modified Rankin Scale (mRS) score (range, 0 [worst] to 1 [best]) at 90 (±14) days. Linear regression models were used to test the harm-futility boundaries of a 10-mL increase (slope of 0.5) in the follow-up infarct volume or a 0.10 decrease (slope of −0.005) in the utility-weighted mRS score with each 20-mm Hg SBP target reduction after endovascular therapy (1-sided α = .05). Additional prespecified futility criterion was a less than 25% predicted probability of success for a future 2-group, superiority trial comparing SBP targets of the low- and mid-thresholds with the high-threshold (maximum sample size, 1500 with respect to the utility-weighted mRS score outcome).ResultsAmong 120 patients randomized (mean [SD] age, 69.6 [14.5] years; 69 females [58%]), 113 (94.2%) completed the trial. The mean follow-up infarct volume was 32.4 mL (95% CI, 18.0 to 46.7 mL) for the less than 140–mm Hg group, 50.7 mL (95% CI, 33.7 to 67.7 mL), for the less than 160–mm Hg group, and 46.4 mL (95% CI, 24.5 to 68.2 mL) for the 180–mm Hg or less group. The mean utility-weighted mRS score was 0.51 (95% CI, 0.38 to 0.63) for the less than 140–mm Hg group, 0.47 (95% CI, 0.35 to 0.60) for the less than 160–mm Hg group, and 0.58 (95% CI, 0.46 to 0.71) for the high-target group. The slope of the follow-up infarct volume for each mm Hg decrease in the SBP target, adjusted for the baseline Alberta Stroke Program Early CT score, was −0.29 (95% CI, −0.81 to ∞; futility P = .99). The slope of the utility-weighted mRS score for each mm Hg decrease in the SBP target after endovascular therapy, adjusted for baseline utility-weighted mRS score, was −0.0019 (95% CI, −∞ to 0.0017; futility P = .93). Comparing the high-target SBP group with the lower-target groups, the predicted probability of success for a future trial was 25% for the less than 140–mm Hg group and 14% for the 160–mm Hg group.Conclusions and RelevanceAmong patients with acute ischemic stroke, lower SBP targets less than either 140 mm Hg or 160 mm Hg after successful endovascular therapy did not meet prespecified criteria for futility compared with an SBP target of 180 mm Hg or less. However, the findings suggested a low probability of benefit from lower SBP targets after endovascular therapy if tested in a future larger trial.Trial RegistrationClinicalTrials.gov Identifier: NCT04116112

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

Nam,

Kim,

Heo

et al. 2023

JAMA

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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 &lt;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

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Blood Pressure Goals and Clinical Outcomes after Successful Endovascular Therapy: A Multicenter Study

Cited by 57 publications

References 30 publications

Impact of Blood Pressure After Successful Endovascular Therapy for Anterior Acute Ischemic Stroke: A Systematic Review

Impact of Blood Pressure After Successful Endovascular Therapy for Anterior Acute Ischemic Stroke: A Systematic Review

Blood Pressure Management After Endovascular Therapy for Acute Ischemic Stroke

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

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