Still no blood pressure management protocol. Hope your doctor GUESSES CORRECTLY after your stroke.
Intensive Versus Conservative Blood Pressure Target After Thrombectomy: A Systematic Review and Meta‐Analysis of Randomized Controlled Trials
INTRODUCTION
The
optimal blood pressure (BP) management following endovascular
thrombectomy (EVT) for acute ischemic stroke remains unclear. The
balance between maintaining adequate cerebral blood flow and preventing
reperfusion injury requires the need of an evidence‐based decision.
Recently, 4 randomized controlled trials (RCTs) focusing on post‐EVT BP
goals were published, showing significantly lower functional
independence in the intensive BP target groups. However, 2 of these
trials were prematurely terminated, which may have limited the
assessment of important secondary outcomes. Therefore, we performed a
meta‐analysis of RCTs comparing intensive versus conservative BP target
for patients following EVT after acute ischemic stroke.
METHODS
We
conducted a meta‐analysis according to the Cochrane Collaboration
Handbook for Systematic Reviews of Interventions and the Preferred
Reporting Items for Systematic Reviews and Meta‐Analysis Statement
(Supplemental Methods 1). This meta‐analysis protocol was registered at
the International Prospective Register of Systematic Reviews
(CRD42023473691). We systematically searched PubMed, Embase, Cochrane,
and ClinicalTrials.gov from inception to October 2023. Studies were
eligible if they (1) were RCTs; (2) enrolled patients with acute
ischemic stroke undergoing EVT; and (3) compared intensive versus
conservative BP target. The inclusion and exclusion criteria of each
study are detailed in Supplemental Methods 2. Our end points were (1) a
modified Rankin scale score (0–2); (2) 24‐hour National Institutes of
Health Stroke Scale score; (3) 3‐month EuroQoL (Quality of
Life)‐5‐Dimension‐3‐Level score; (4) all‐cause mortality; and (5)
symptomatic intracranial hemorrhage within 36 hours. We evaluated the
risk of bias of included RCTs with the Risk of Bias Tool. We conducted a
trial sequential analysis for all‐cause mortality.
We
used restricted maximum likelihood random‐effects model with risk
ratios and 95% CIs for binary end points and mean differences or
standardized mean difference for continuous end points. Heterogeneity
was assessed using Cochrane's Q statistic and Higgins and Thompson's I2 statistic. P
value <0.05 was considered statistically significant. We used R
version 4.3.1 and trial sequential analysis version 0.9.5.10 beta for
statistical analysis.
RESULTS
Our systematic search yielded 1249 potential articles, of which 4 RCTs met inclusion criteria.1, 2, 3, 4
A total of 1565 patients were included, of whom 764 (48.8%) were
randomized to intensive BP target. The mean 24‐hour SBP after EVT varied
from 120.8 to 129.2 mmHg in the intensive BP target group, and from
129.5 to 139 mmHg in the conservative BP target group.
Functional
independence after 90 days was significantly less frequent with
intensive BP target compared with the conservative group (risk ratio
0.80 [95% CI, 0.71–0.90]; I2 = 10%; P<0.01; Figure 1A).
An intensive BP target resulted in a lower 3‐month EuroQoL (quality of
life)‐5‐Dimension 3‐Level scores (standardized mean difference −0.24
[95% CI, −0.37 to −0.12]; I2 = 0%; P<0.01; Figure 1B).
There were no significant differences in 24‐hour National Institutes of
Health Stroke Scale score (mean difference 0.93 [95% CI, −0.36 to
2.22]; I2 = 48%; P = 0.16; Figure 1C), all‐cause mortality (risk ratio 1.15 [95% CI, 0.90–1.48]; I2 = 0%; P = 0.26; Figure 1D), and symptomatic intracranial hemorrhage within 36 hours (risk ratio 1.13 [95% CI, 0.78–1.63]; I2 = 0%; P = 0.52; Figure 1E).
Risk of Bias Tool 2 identified all studies as low risk of bias. The
z‐curve did not cross the required information size, conventional, and
monitoring boundaries. In addition, the inner wedge is not reached.
These findings suggest that more studies are needed to confirm our
results (Supplemental Figure 3).
DISCUSSION
Our
study found no differences in either all‐cause mortality or symptomatic
intracranial hemorrhage between groups. This is consistent with the
individual results of the 4 included RCTs, suggesting a high probability
of neutrality between both strategies in these outcomes. However,
functional independence (modified Rankin scale score 0–2) was 23% more
frequent in the conservative as compared to the intensive group.
Furthermore, the SBP <140 mm Hg goal was associated with reduced
quality of life score.
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