Deans' stroke musings: Lowering blood pressure after clot removal may not be safe; should be individualized

Changing stroke rehab and research worldwide now.Time is Brain! trillions and trillions of neurons that DIE each day because there are NO effective hyperacute therapies besides tPA(only 12% effective). I have 523 posts on hyperacute therapy, enough for researchers to spend decades proving them out. These are my personal ideas and blog on stroke rehabilitation and stroke research. Do not attempt any of these without checking with your medical provider. Unless you join me in agitating, when you need these therapies they won't be there.

What this blog is for:

My blog is not to help survivors recover, it is to have the 10 million yearly stroke survivors light fires underneath their doctors, stroke hospitals and stroke researchers to get stroke solved. 100% recovery. The stroke medical world is completely failing at that goal, they don't even have it as a goal. Shortly after getting out of the hospital and getting NO information on the process or protocols of stroke rehabilitation and recovery I started searching on the internet and found that no other survivor received useful information. This is an attempt to cover all stroke rehabilitation information that should be readily available to survivors so they can talk with informed knowledge to their medical staff. It lays out what needs to be done to get stroke survivors closer to 100% recovery. It's quite disgusting that this information is not available from every stroke association and doctors group.

Saturday, February 11, 2023

Lowering blood pressure after clot removal may not be safe; should be individualized

This makes perfect sense, less blood pressure means less oxygen being delivered to the brain probably hastening the death of those neurons in the penumbra. So we still have no blood pressure management protocol and it seems likely it will stay that way for a long time with NO STROKE LEADERSHIP. Hope your doctor guesses right on blood pressure post stroke. Will your doctor guarantee no bad effects from their guesses on blood pressure management?

Lowering blood pressure after clot removal may not be safe; should be individualized

American Stroke Association International Stroke Conference – Late-Breaking Science Presentation LB 18

Research Highlights:

Using blood pressure medications to lower systolic blood pressure immediately after mechanical clot removal (endovascular treatment) for acute ischemic stroke may not be safe or effective and should be considered with caution and individualized to each patient, according to a preliminary study.
At 36 hours, stroke volumes showed no conclusive evidence of harm, and after 90 days, the disability outcome showed only a slight indication of harm. The researchers concluded that individualized blood pressure control may be the way forward.

Embargoed until 11:37 a.m. CT/12:37 p.m. ET Friday, Feb. 10, 2023

DALLAS, Feb. 10, 2023 — Using blood pressure medications to lower the top number of blood pressure reading (systolic blood pressure) may not be safe or effective among people who have an acute ischemic stroke and undergo a successful mechanical clot removal — endovascular therapy, according to a phase-2 late-breaking clinical trial presented today at the American Stroke Association’s International Stroke Conference 2023. The meeting, to be held in person in Dallas and virtually, Feb. 8-10, 2023, is a world premier meeting for researchers and clinicians dedicated to the science of stroke and brain health.

“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 lead study author Eva Mistry, M.B.B.S., a stroke neurologist and assistant professor in the department of neurology and rehabilitation medicine at the University of Cincinnati in Ohio.

“Individual patients might require lowering of blood pressure due to medical and neurological reasons, however, it should not be done as blanket practice with all patients. It may benefit some patients and needs to be customized,” she said.

“Endovascular therapy has changed the landscape in acute stroke treatment,” she continued. “Patients do drastically better when they receive endovascular treatment, compared to when they don’t. And, despite the enormous effectiveness of endovascular treatment, about 50% of patients remain disabled or die at 90 days, so we are on a quest to understand if there are additional strategies that may further improve outcomes in these patients.”

Previous research has indicated that higher systolic blood pressure after endovascular treatment is associated with greater disability in people who have had an acute ischemic stroke (most common type of stroke caused by a blockage). Endovascular treatment is a catheter-based therapy used to remove a blood clot blocking arteries and thereby restoring blood flow. Systolic blood pressure between 140 mm Hg and 160 mm Hg has been associated with better outcomes following the procedure. Normal blood pressure is considered as less than 120 mm Hg systolic (top number in a blood pressure reading) and less than 80 mm Hg diastolic (bottom number in a blood pressure reading). However, whether using blood pressure medications to artificially lower systolic blood pressure to less than 180 mm Hg is safe and effective has not been demonstrated following clot removal.

“There is always the concern if blood pressure is lowered too much in patients who are having an acute ischemic stroke that it could make the size of their stroke worse by reducing already compromised blood flow in that area,” Mistry explained.

In this study, called Blood Pressure After Endovascular Stroke Treatment, or BEST II, researchers hypothesized that patients allocated to lowering systolic blood pressure targets might have a higher volume of stroke size at 36 hours and a higher disability at 90 days.

Researchers enrolled 120 patients (average age of 70 years, 57% female) who had an acute ischemic stroke and successful endovascular treatment at one of three urban comprehensive stroke centers (Vanderbilt University Medical Center in Tennessee; University of Cincinnati in Ohio; and Hartford Health Medical Center in Connecticut) between January 2020 and February 2022. Forty patients were randomly assigned to have their systolic blood pressure lowered to a target of less than or equal to 180 mm Hg; 40 patients were assigned to a systolic blood pressure target of less than 160 mm Hg; and 40 patients were targeted to reach a systolic blood pressure of less than 140 mm Hg. Patients were treated with an anti-hypertensive medication called nicardipine, administered intravenously, started within one hour after endovascular treatment and given for 24 hours if their systolic blood pressure was above the target they were assigned. Researchers wanted to assess whether lowering blood pressure may cause harm to brain tissue, which is particularly vulnerable during the 24 hours after a stroke, and to assess disability 90 days later.

The study found:

In the less than or equal to 180 mm Hg-target group, average systolic blood pressure reached 129 mm Hg.
In the below 160 mm Hg-target group, the average systolic blood pressure reached 130 mm Hg.
In the less than 140 mm Hg-target group, systolic blood pressure was lowered to an average of 123 mm Hg.
The average 36-hour stroke volumes showed no conclusive evidence of harm.
In the 90-day disability outcome, there was only a slight indication of harm.

“The main outcomes of the study were the size of stroke at 36 hours and degree of disability at 90-days,” Mistry said. “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 said. “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.”

The study’s limitations include the small number of patients involved in the trial. Additionally, because the trial was conducted at three centers, the results may not apply to stroke patients treated elsewhere.

Study co-authors are Kimberly Hart, Ph.D.; Larry Davis, M.D.; Yue Gao, M.S., M.Ed.; Charles Joseph Prestigiacomo, M.D.; Shilpi Mittal, M.D.; Tapan Mehta, M.D.; Hayden Lafever, Ph.D.; Pablo Harker; Hilary Perez; Kalli Beasley, M.P.H.; Neeharika Krothapalli, M.D.; Emily Lippincott, M.D.; Heather Stefek, M.D.; Michael Froehler, M.D., Ph.D.; Rohan Chitale, M.D.; Matthew Fusco, M.D.; Aaron W. Grossman, M.D., Ph.D.; Peyman Shirani, M.D.; Matthew Smith, M.D.; Matthew N. Jaffa, D.O.; Sharon D. Yeatts, Ph.D.; Gregory W. Albers, M.D.; Jonathan Wanderer, M.D., M.Phil.; Juliana Tolles, M.D.; Christopher Lindsell, Ph.D.; Roger Jay Lewis, M.D., Ph.D.; Gordon R. Bernard, M.D.; and Pooja Khatri, M.D., M.Sc. The list of authors’ disclosures is available in the abstract.

The National Institute of Neurological Disorders and Stroke, a division of the National Institutes of Health, funded the study.

Statements and conclusions of studies that are presented at the American Heart Association’s scientific meetings are solely those of the study authors and do not necessarily reflect the Association’s policy or position. The Association makes no representation or guarantee as to their accuracy or reliability. Abstracts presented at the Association’s scientific meetings are not peer-reviewed, rather, they are curated by independent review panels and are considered based on the potential to add to the diversity of scientific issues and views discussed at the meeting. The findings are considered preliminary until published as a full manuscript in a peer-reviewed scientific journal.

The Association receives funding primarily from individuals; foundations and corporations (including pharmaceutical, device manufacturers and other companies) also make donations and fund specific Association programs and events. The Association has strict policies to prevent these relationships from influencing the science content. Revenues from pharmaceutical and biotech companies, device manufacturers and health insurance providers and the Association’s overall financial information are available here.

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