Successful Revascularization Outcomes Associated With Lower Systemic Blood Pressure

March 31, 2020

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Mohammad Anadani, MD

Data from a multicenter study suggest that systemic blood pressure (SBP) goals <140 and <160 mmHg following successful revascularization (SR) with endovascular therapy (EVT) are associated with better clinical outcomes than an SBP goal of <180 mmHg.

Using an inverse probably of treatment weighting (IPTW) propensity analysis, researchers found there was a higher likelihood of good functional outcome and lower odds of hemicraniectomy in patients with SBP goal <140 mmHg compared to SBP <180 mmHg.

This retrospective, multicenter, international study headed by Mohammad Anadani, MD, neurocritical care fellow, Washington University in St. Louis, featured 1019 patients who presented with anterior circulation large vessel occlusion (LVO) and were treated with EVT with SR at the end of the procedure. Across the 8 comprehensive stroke centers, data were collected to compare the functional and safety outcomes between different SBP goals following EVT with SR. Researchers used scores >2B on modified Thrombolysis in Cerebral Ischemia (mTICI) as a way to define SR.

Patients included in the study had median pre-stroke modified Rankin Scale (mRS) scores of 0—2 and baseline Alberta Stroke Program Early CT Score (ASPECTS) scores of >6.

Operators would assess BPG at the end of thrombectomy or according to institutional protocol. Within the first 24 hours following EVT, patients were divided into 3 separate groups according to their SBP goals. These included an intensive blood pressure control (IN-BP) group, with patients who had SBP goal <140 mmHg, moderate blood pressure (MO-BP) group with SBP goal <160 mmHg and guideline-recommended blood pressure control (GI-BP) group which included patients with SBP goal <180 mmHg.

At baseline, researchers gathered data on characteristics such as age, sex, race, comorbidities, admission National Institute of Health Stroke Scale (NIHSS) scores, location of occlusion, ASPECTS score, onset-to-groin puncture time (minutes), and whether intravenous tissue plasmogen activator (IV-tPA) was used. Anadani and colleagues used mRS scores at 90 days to assess functional outcome. Scores between 0—2 were defined as good clinical outcome. Other additional safety outcomes included symptomatic intracranial hemorrhage (sICH), all-cause 90-day mortality, and rescue therapy with hemicraniectomy during hospitalization.

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The study originally had 1063 participants, but was shrunk to 1019 patients (mean age, 68 years; 50% women; median admission NIHSS-score, 16; median ASPECTS score, 9; median onset to groin puncture time, 231 minutes; 56% pretreated with IVT; 55% achieved mTICI 3 at the end of the procedure) upon inclusion criteria.

Following the procedure, 540 (53%) patients were in IN-BP, 142 (14%) in MO-BP, and 337 (33%) in GI-BP. Researchers noted a shorter median onset to groin time in the GI-BP group than in both IN-BP and MO-BP groups (246 vs. 288 and 301 minutes respectively; P <.05).

IN-BP was associated with greater odds of good functional outcome compared to GI-BP on IPTW-adjusted multivariate analysis (OR, 1.53; 95% CI, 1.07—2.19). In addition to that, MO-BP was found to not be related to a higher likelihood of good functional outcome (OR, 1.58; 95% CI, 0.06–2.59).

At 90 days, good clinical outcome was achieved in 52%, 52%, and 44% in the IN-BP, MO-BP, and GI-BP subgroups, respectively.

As for poor outcomes, sICH was found in 3% of patients in IN-BP, 8% of patients in MO-BP, and 5% of patients in the GI-BP group. In the IN-BP, MO-BP and GI-BP groups, the rates of 90-day mortality were 16%, 14% and 21%, respectively. Lastly, 2% of patients in the IN-BP group experienced hemicraniectomy during hospitalization, compared to 10% in MO-BP and 6% in the GI-BP group.

“Our results suggest that systolic blood pressure goals lower than the currently recommended cut-off of 180 mmHg may improve safety and efficacy outcomes of endovascular therapy; therefore, a well-designed, adequately powered, randomized-controlled clinical trials evaluating the benefit of blood pressure control in LVO patients with successful recanalization following EVT are urgently needed,” Anadani et al. concluded.

REFERENCE

Anadani M, Arthur AS, Tsivgoulis G, et al. Blood pressure goals and clinical outcomes after successful endovascular therapy: a multicenter study. Ann Neurol. Published online March 18, 2020. doi: 10.1002/ana.25716.