Intensive vs Conventional Blood Pressure Lowering After Endovascular Thrombectomy in Acute Ischemic Stroke
Authors: Nam Hyo Suk , Kim Young Dae , Heo JoonNyung , Lee Hyungwoo , Jung Jae Wook , Choi Jin Kyo , Lee Il Hyung , Lim In Hwan , Hong Soon-Ho , Baik Minyoul , Kim Byung Moon , Kim Dong Joon , Shin Na-Young , Cho Bang-Hoon , Ahn Seong Hwan , Park Hyungjong , Sohn Sung-Il , Hong Jeong-Ho , Song Tae-Jin , Chang Yoonkyung , Kim Gyu Sik , Seo Kwon-Duk , Lee Kijeong , Chang Jun Young , Seo Jung Hwa , Lee Sukyoon , Baek Jang-Hyun , Cho Han-Jin , Shin Dong Hoon , Kim Jinkwon , Yoo Joonsang , Lee Kyung-Yul , Jung Yo Han , Hwang Yang-Ha , Kim Chi Kyung , Kim Jae Guk , Lee Chan Joo , Park Sungha , Lee Hye Sun , Kwon Sun U. , Bang Oh Young , Anderson Craig S. , Heo Ji Hoe ,   OPTIMAL-BP Trial Investigators, Jeon Soyoung , Choi Solji , Ko You Yeon , Lee Hyemi , Kim Mi Hee , Song Seungmin , Oh Han Sol , Kim Heejeong , chang Okkyung , Jeong Giseon , Kim Moonju , Shin Hyun Jung , Han Su-jin , Jeong Hajeong , Kim A Young , Bang Joohee , Shin Joeng A , Bae Jin Suk 
Published: September 2023

Importance

Optimal blood pressure (BP) control after successful reperfusion with endovascular thrombectomy (EVT) for patients with acute ischemic stroke is unclear.

Objective

To 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 Participants

Multicenter, 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).

Interventions

Participants were randomly assigned to receive intensive BP management (systolic BP target &amp;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 Measures

The 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.

Results

The 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 Relevance

Among 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 Registration

ClinicalTrials.gov Identifier: NCT04205305