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Meta-Analysis
. 2023 Apr;22(4):312-319.
doi: 10.1016/S1474-4422(23)00076-5.

Admission systolic blood pressure and effect of endovascular treatment in patients with ischaemic stroke: an individual patient data meta-analysis

Noor Samuels  1 , Rob A van de Graaf  2 , Maxim J H L Mulder  3 , Scott Brown  4 , Bob Roozenbeek  2 , Pieter Jan van Doormaal  5 , Mayank Goyal  6 , Bruce C V Campbell  7 , Keith W Muir  8 , Nelly Agrinier  9 , Serge Bracard  10 , Phil M White  11 , Luis San Román  12 , Tudor G Jovin  13 , Michael D Hill  6 , Peter J Mitchell  14 , Andrew M Demchuk  6 , Alain Bonafe  15 , Thomas G Devlin  16 , Adriaan C G M van Es  5 , Hester F Lingsma  17 , Diederik W J Dippel  3 , Aad van der Lugt  5 ; HERMES Collaborators
Affiliations
Meta-Analysis

Admission systolic blood pressure and effect of endovascular treatment in patients with ischaemic stroke: an individual patient data meta-analysis

Noor Samuels et al. Lancet Neurol. 2023 Apr.

Abstract

Background: Current guidelines for ischaemic stroke treatment recommend a strict, but arbitrary, upper threshold of 185/110 mm Hg for blood pressure before endovascular thrombectomy. Nevertheless, whether admission blood pressure influences the effect of endovascular thrombectomy on outcome remains unknown. Our aim was to study the influence of admission systolic blood pressure (SBP) on functional outcome and on the effect of endovascular thrombectomy.

Methods: We used individual patient data from seven randomised controlled trials (MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, REVASCAT, PISTE, and THRACE) that randomly assigned patients with anterior circulation ischaemic stroke to endovascular thrombectomy (predominantly using stent retrievers) or standard medical therapy (control) between June 1, 2010, and April 30, 2015. We included all patients for whom SBP data were available at hospital admission. The primary outcome was functional outcome (modified Rankin Scale) at 90 days. We assessed the association of SBP with outcome in both the endovascular thrombectomy group and the control group using multilevel regression analysis and tested for non-linearity and for interaction between SBP and effect of endovascular thrombectomy, taking into account treatment with intravenous thrombolysis.

Findings: We included 1753 patients (867 assigned to endovascular thrombectomy, 886 assigned to control) after excluding 11 patients for whom SBP data were missing. We found a non-linear association between SBP and functional outcome with an inflection point at 140 mm Hg (732 [42%] of 1753 patients had SBP <140 mm Hg and 1021 [58%] had SBP ≥140 mm Hg). Among patients with SBP of 140 mm Hg or higher, admission SBP was associated with worse functional outcome (adjusted common odds ratio [acOR] 0·86 per 10 mm Hg SBP increase; 95% CI 0·81-0·91). We found no association between SBP and functional outcome in patients with SBP less than 140 mm Hg (acOR 0·97 per 10 mm Hg SBP decrease, 95% CI 0·88-1·05). There was no significant interaction between SBP and effect of endovascular thrombectomy on functional outcome (p=0·96).

Interpretation: In our meta-analysis, high admission SBP was associated with worse functional outcome after stroke, but SBP did not seem to negate the effect of endovascular thrombectomy. This finding suggests that admission SBP should not form the basis for decisions to withhold or delay endovascular thrombectomy for ischaemic stroke, but randomised trials are needed to further investigate this possibility.

Funding: Medtronic.

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Conflict of interest statement

Declaration of interests SB reports personal fees from the University of Calgary during the conduct of the HERMES collaboration and membership on a data safety monitoring board (DSMB) for the TESLA trial, no payment accepted. MG reports that Medtronic, NoNO, and Cerenovus provided a grant to the University of Calgary; royalties or licenses from GE Healthcare for systems of acute stroke diagnosis and Microventric for systems of intracranial access; consulting fees from Medtronic, Microvention, Stryker, and Mentice; and holds stock in Circle Neurovascular. KWM reports a grant from Boehringer Ingelheim payed to the institution for support of the ATTEST-2 trial; consulting fees from Boehringer Ingelheim, AbbVie, and Biogen; and BHF-funded DSMB participation (ARREST trial). PMW reports unrestricted grants from Stryker, Medtronic (Covidien), and Penumbra payed to the institution. TGJ reports honoraria from Stryker, Silk Road Medical, Blockade Medical, FreeOx Biomedical, Route 92, Neurotrauma Science, Viz.ai, Corindus, Anaconda, Medtronic, Contego, and Methinks as a consultant; and has consulted for Cerenovus as a steering committee member and Stryker Neurovascular as a principal investigator of DAWN and AURORA. MDH reports a research grant from Medtronic paid to the University of Calgary for the HERMES collaboration; grants all paid to the University of Calgary from Boehringer-Ingelheim (for the TEMPO-2 trial), Biogen, NoNO (for the ESCAPE-NA1 trial, ESCAPE-NEXT trial), Canadian Institutes for Health Research (for the ESCAPE-NA1 trial, ESCAPE-NEXT trial), and Alberta Innovates (for the QuICR Alberta Stroke Program; some of the funds were used for the ESCAPE-NA1 trial). MDH also reports paid work for Sun Pharma and Brainsgate for adjudication of clinical trial outcomes; patents (US Patent 62/086,077 and US Patent 10,916,346) licensed to Circle NVI; and participation as a DSMB chair for the RACECAT trial (end 2020), Oncovir Hiltonel trial (ongoing), and DUMAS trial (ongoing), and DSMB member for the ARTESIA trial (ongoing) and BRAIN-AF trial (ongoing). MDH is president of the Canadian Neurological Sciences Federation (not for profit), board member of the Canadian Stroke Consortium (not for profit), and holds stock in Circle and PureWeb. PJM reports speaking engagements from Stryker and Medtronic and research institutional support from Stryker Neurovascular and Medtronic. AMD reports honoraria from Medtronic, grants from Cerenovus for the ENDOLOW trial, and participated in a DSMB for the WE-TRUST trial (Philips). DWJD reports unrestricted research grants from the Dutch Heart Foundation, Brain Foundation Netherlands, The Netherlands Organisation for Health Research and Development, Health Holland Top Sector Life Sciences and Health, and unrestricted grants from Medtronic, Penumbra, Stryker, Thrombolytic Science, and Cerenovus (all paid to institution). AvdL reports grants from Dutch Heart Foundation, Brain Foundation Netherlands, The Netherlands Organization for Health Research and Development, Health Holland Top Sector Life Sciences & Health, Stryker, Penumbra, Medtronic, Cerenovus, Thrombolytic Science, GE Healthcare, Siemens Healthineers, and Philips Healthcare (all paid to his institution). AvdL also reports speaking fees from Siemens Healthineers paid to the institution, participation on a DSMB for the ESCAPE-MEVO trial, and is research leader of CONTRAST consortium (unpaid). All other authors declare no competing interests.

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