Intensive blood pressure control post-endovascular thrombectomy after acute ischemic stroke linked with worse clinical outcomes

1. More intensive blood pressure targets were associated with poor functional outcome at 90 days, neurological deterioration, and major disability compared to less intensive targets.

2. Major intracerebral hemorrhage and all-cause mortality were comparable between groups.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Management of systolic blood pressure (sBP) post-endovascular thrombectomy is critical for preventing complications following acute ischemic strokes. However, this must be done with caution as a significant drop in sBP may compromise tissue perfusion. The optimal sBP target in patients following endovascular thrombectomy remains unclear. This randomized trial aimed to compare the safety and efficacy of different blood pressure targets in patients with elevated systolic blood pressure post-endovascular thrombectomy. The primary outcome was functional recovery at 90 days, as defined by the modified Rankin scale (range 0-6, 0 = no symptoms, 6 = death) while key secondary outcomes included death or neurological deterioration at day 7. According to study results, more intensive BP management (sBP <120 mmHg) may compromise functional recovery and should be avoided in patients with recent endovascular thrombectomy. The more intensive BP target group was more likely to have neurologic deterioration and major disabilities compared to the less intensive group. However, major cerebral hemorrhage was comparable between study groups. This study was strengthened by a large sample size with patients from multiple hospitals in China, thus increasing its validity.

Click to read the study in The Lancet

Relevant Reading: Trial of Intensive Blood-Pressure Control in Older Patients with Hypertension

In-depth [randomized-controlled trial]: Between July 20, 2020, and March 7, 2022, 1828 patients were screened for eligibility at 44 tertiary care centers in China. Included were ≥ 18 years old who had undergone endovascular thrombectomy for acute ischemic stroke and had a sustained elevated systolic blood pressure (≥140 mmHg for <10 mins). Altogether, 799 patients (398 to more intensive treatment group and 401 to less intensive treatment group) were included in the per-protocol analysis. The primary outcome of poor functional outcome at 90 days post-thrombectomy was greater in the more intensive group than in the less intensive blood pressure control group (odds ratio [OR] 1.37, 95% confidence interval [CI] 1.07-1.76). Similarly, a greater proportion of patients in the more intensive group had neurological deterioration at seven days (OR 1.53, 95% CI 1.18-1.97) and major disability at three months (OR 2.07, 95% CI 1.47-2.93). Symptomatic intracerebral hemorrhage (6% each) and all-cause mortality (16% in more intensive group vs. 15% in less intensive group) were comparable. Overall, findings from this study suggest that less intensive therapy (sBP <140-180 mmHg) is preferred in patients with elevated sBP post-endovascular thrombectomy.

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