We've known of this problem for years! SOLVE IT BY CREATING BLOOD PRESSURE MANAGEMENT PROTOCOLS! Don't just tell us a problem exists, I'd fire anyone who doesn't solve the problem directly in front of them! No excuses!
blood pressure management (68 posts to June 2017)
Blood Pressure Management After Endovascular Therapy for Acute Ischemic Stroke
The BEST-II Randomized Clinical Trial
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EditorialBlood Pressure Management After Successful ThrombectomyAmrou Sarraj, MDJAMA
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Original InvestigationIntensive vs Conventional Blood Pressure Lowering After Endovascular Thrombectomy in Acute Ischemic StrokeHyo Suk Nam, MD, PhD; Young Dae Kim, MD, PhD; JoonNyung Heo, MD; Hyungwoo Lee, MD; Jae Wook Jung, MD; Jin Kyo Choi, MD; Il Hyung Lee, MD; In Hwan Lim, MD; Soon-Ho Hong, MD; Minyoul Baik, MD; Byung Moon Kim, MD, PhD; Dong Joon Kim, MD, PhD; Na-Young Shin, MD; Bang-Hoon Cho, MD; Seong Hwan Ahn, MD; Hyungjong Park, MD; Sung-Il Sohn, MD, PhD; Jeong-Ho Hong, MD, PhD; Tae-Jin Song, MD, PhD; Yoonkyung Chang, MD, PhD; Gyu Sik Kim, MD; Kwon-Duk Seo, MD; Kijeong Lee, MD; Jun Young Chang, MD, PhD; Jung Hwa Seo, MD; Sukyoon Lee, MD; Jang-Hyun Baek, MD; Han-Jin Cho, MD, PhD; Dong Hoon Shin, MD, PhD; Jinkwon Kim, MD, PhD; Joonsang Yoo, MD; Kyung-Yul Lee, MD; Yo Han Jung, MD, PhD; Yang-Ha Hwang, MD, PhD; Chi Kyung Kim, MD, PhD; Jae Guk Kim, MD; Chan Joo Lee, MD, PhD; Sungha Park, MD, PhD; Hye Sun Lee, PhD; Sun U. Kwon, MD, PhD; Oh Young Bang, MD, PhD; Craig S. Anderson, MBBS, PhD; Ji Hoe Heo, MD, PhD; OPTIMAL-BP Trial Investigators; Soyoung Jeon; Solji Choi; You Yeon Ko ; Hyemi Lee; Mi Hee Kim; Seungmin Song; Han Sol Oh; Heejeong Kim; Okkyung chang; Giseon Jeong; Moonju Kim; Hyun Jung Shin; Su-jin Han; Hajeong Jeong; A Young Kim; Joohee Bang; Joeng A Shin; Jin Suk BaeJAMA
Question Are moderately low systolic blood pressure (SBP) targets (<140 and <160 mm Hg) after successful endovascular stroke treatment harmful?
Findings In this futility-design, randomized clinical trial that included 120 participants, SBP targets of less than either 140 or 160 mm Hg vs the guideline-recommended target of 180 mm Hg or less did not meet prespecified criteria for futility or harm for follow-up infarct volume and 90-day utility-weighted modified Rankin Scale (mRS) score. Based on the utility-weighted mRS score, the predicted probability of success in a future larger clinical trial for an SBP target of less than either 140 mm Hg or 160 mm Hg vs 180 mm Hg or less was 25% and 14%, respectively.
Meaning Lower SBP targets after successful endovascular therapy for acute ischemic stroke did not meet the criteria for futility, although the findings suggested a low probability of benefit from lower SBP targets if tested in a future larger trial.
Importance The effects of moderate systolic blood pressure (SBP) lowering after successful recanalization with endovascular therapy for acute ischemic stroke are uncertain.
Objective To determine the futility of lower SBP targets after endovascular therapy (<140 mm Hg or 160 mm Hg) compared with a higher target (≤180 mm Hg).
Design, Setting, and Participants Randomized, open-label, blinded end point, phase 2, futility clinical trial that enrolled 120 patients with acute ischemic stroke who had undergone successful endovascular therapy at 3 US comprehensive stroke centers from January 2020 to March 2022 (final follow-up, June 2022).
Intervention After undergoing endovascular therapy, participants were randomized to 1 of 3 SBP targets: 40 to less than 140 mm Hg, 40 to less than 160 mm Hg, and 40 to 180 mm Hg or less (guideline recommended) group, initiated within 60 minutes of recanalization and maintained for 24 hours.
Main Outcomes and Measures Prespecified multiple primary outcomes for the primary futility analysis were follow-up infarct volume measured at 36 (±12) hours and utility-weighted modified Rankin Scale (mRS) score (range, 0 [worst] to 1 [best]) at 90 (±14) days. Linear regression models were used to test the harm-futility boundaries of a 10-mL increase (slope of 0.5) in the follow-up infarct volume or a 0.10 decrease (slope of −0.005) in the utility-weighted mRS score with each 20-mm Hg SBP target reduction after endovascular therapy (1-sided α = .05). Additional prespecified futility criterion was a less than 25% predicted probability of success for a future 2-group, superiority trial comparing SBP targets of the low- and mid-thresholds with the high-threshold (maximum sample size, 1500 with respect to the utility-weighted mRS score outcome).
Results Among 120 patients randomized (mean [SD] age, 69.6 [14.5] years; 69 females [58%]), 113 (94.2%) completed the trial. The mean follow-up infarct volume was 32.4 mL (95% CI, 18.0 to 46.7 mL) for the less than 140–mm Hg group, 50.7 mL (95% CI, 33.7 to 67.7 mL), for the less than 160–mm Hg group, and 46.4 mL (95% CI, 24.5 to 68.2 mL) for the 180–mm Hg or less group. The mean utility-weighted mRS score was 0.51 (95% CI, 0.38 to 0.63) for the less than 140–mm Hg group, 0.47 (95% CI, 0.35 to 0.60) for the less than 160–mm Hg group, and 0.58 (95% CI, 0.46 to 0.71) for the high-target group. The slope of the follow-up infarct volume for each mm Hg decrease in the SBP target, adjusted for the baseline Alberta Stroke Program Early CT score, was −0.29 (95% CI, −0.81 to ∞; futility P = .99). The slope of the utility-weighted mRS score for each mm Hg decrease in the SBP target after endovascular therapy, adjusted for baseline utility-weighted mRS score, was −0.0019 (95% CI, −∞ to 0.0017; futility P = .93). Comparing the high-target SBP group with the lower-target groups, the predicted probability of success for a future trial was 25% for the less than 140–mm Hg group and 14% for the 160–mm Hg group.
Conclusions and Relevance Among patients with acute ischemic stroke, lower SBP targets less than either 140 mm Hg or 160 mm Hg after successful endovascular therapy did not meet prespecified criteria for futility compared with an SBP target of 180 mm Hg or less. However, the findings suggested a low probability of benefit from lower SBP targets after endovascular therapy if tested in a future larger trial.
Trial Registration ClinicalTrials.gov Identifier: NCT04116112
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