Blood Pressure Medications Not Safe or Effective in Lowering Top Number of BP Reading After Endovascular Stroke Treatment

Eva Mistry, MBBS

New findings from the phase 2 randomized, open label, BEST-II trial (NCT04116112) of 120 patients with acute ischemic stroke suggested that use of blood pressure medications (BPM) to lower systolic blood pressure immediately following endovascular treatment (EVT) for acute ischemic stroke may not be safe or effective.

All told, there was no evidence of significant harm to stroke volumes at 36 hours, and only a slight indication of harm after 90 days on disability outcome.¹ The results helped inform the safety of lower SBP for patients with acute ischemic stroke following EVT and why individualized blood pressure control may be the way forward.

Patients were randomly assigned to have their systolic blood pressure lowered to a targeted SBP (n = 40, for SBP lowered to less than or equal to 180 mm Hg; n = 40, SBP to less than 160 mm Hg; and n = 40 SBP of less than 140 mm Hg). The findings showed that average SBP reached 129 mm Hg in the less than or equal to 180 mm Hg-target group, 130 mm Hg in the target group below 160 mm, and lowered to an average of 123 mm Hg in the less than 140 mm Hg-target group.¹

Results were presented as a late breaker by lead author Eva Mistry, MBBS, stroke neurologist and assistant professor in the department of neurology and rehabilitation medicine at the University of Cincinnati in Ohio at the 2023 International Stroke Conference (ISC), February 8-10, in Dallas, Texas. “Health care professionals should be cautious when lowering blood pressure after endovascular treatment, as there are some signs that blood pressure that’s too low may be harmful,” explained Mistry in a statement.²

Investigators enrolled patients with acute ischemic stroke and successful EVT from 3 stroke centers between January 2020 and February 2022. Patients received nicardipine, an anti-hypertensive medication, within one hour after EVT and given 24 hours if their SBP was above their target. The primary study outcomes were infarct volume at 36 hours and 90 days, analyzed with the utility-weighted modified Rankin Scale score. Limitations included the sample of patients involved in the trial and results may not be generalizable because patients came from only three stroke centers.

“The main outcomes of the study were the size of stroke at 36 hours and degree of disability at 90-days,” Mistry noted in a statement.² “Although the study did not find significant evidence of an unequivocal harm of lower blood pressure targets in this population in terms of worsening size of stroke or increasing disability, the trends indicated that there may only be marginal benefit on patients’ long-term disability by lowering blood pressure after endovascular treatment. In fact, there was indication that lowering the blood pressure after thrombectomy may worsen patients’ long-term disability.”

“This study provides indication that patients’ blood pressure should be allowed to be auto regulated after endovascular treatment unless about 180 mm Hg, and clinicians might want to be cautious when they reflexively lower the blood pressure since there may be some signal of harm,” Mistry added in a statement.² “There should be individual patient decision making, such as if there are other medical reasons for lowering the blood pressure or if there are signs of significant bleeding in the brain.”

Prior research indicated that higher systolic blood pressure after EVT is associated with greater disability in patients who experienced an acute ischemic stroke; however, it was unclear on the safety and efficacy of using blood pressure medications to lower systolic blood pressure to less than 180 mm Hg following endovascular treatment.¹

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REFERENCES
1. Mistry E, Hart K, Davis L, et al. Blood Pressure After Endovascular Stroke Treatment (BEST)-II: A Randomized Clinical. Presented at: 2023 International Stroke Conference; February 8-10; Dallas, TX. LB18
2. Lowering blood pressure after clot removal may not be safe; should be individualized. News Release. American Heart Association. Published February 10, 2023. Accessed February 10, 2023. https://newsroom.heart.org/news/lowering-blood-pressure-after-clot-removal-may-not-be-safe-should-be-individualized