Blood pressure management based on infarct volume after successful endovascular thrombectomy

Abstract

Introduction: While the efficacy of endovascular thrombectomy (EVT) in large core infarcts has been established, the influence of blood pressure (BP) management on functional outcomes based on infarct volume remains unclear.

Patients and methods: We conducted a secondary analysis of the Outcome in Patients Treated With Intra-Arterial Thrombectomy-Optimal Blood Pressure Control (OPTIMAL-BP) trial, which compared intensive (systolic BP < 140 mmHg) versus conventional (systolic BP 140-180 mmHg) BP management within the first 24 h following successful recanalization. Patients were grouped based on an infarct volume cut-off of 50 ml, assessed 24 h post-EVT. The primary efficacy outcome was functional independence (modified Rankin Scale of 0-2) at 3 months. Change of predicted probability for functional independence between BP managements, as infarct volume varied, was assessed.

Results: Of the 300 patients, 222 (74.0%) were in the infarct volume ⩽50 ml group and 78 (26.0%) were in the infarct volume >50 ml group. The conventional management was significantly associated with a higher rate of functional independence in the infarct volume ⩽50 ml group (adjusted odds ratio [AOR], 2.06 [95% CI, 1.12-3.86]). In the infarct volume >50 ml group, the proportion of patients with functional independence was not significantly different between BP managements (AOR, 1.52 [95% CI, 0.46-5.04]). The interaction effect between the infarct volume groups and BP managements was not significant. As infarct volume increased, the difference in predicted probability of functional independence between BP managements decreased.

Discussion and conclusions: Conventional BP management showed greater benefits for achieving functional independence at 3 months when infarct volumes were smaller. As infarct volume increased, the impact of BP management strategies on functional outcomes decreased.

Registration: ClinicalTrials.gov (NCT04205305).

Keywords: Endovascular thrombectomy; antihypertensives; blood pressure; cerebral infarction volume.

Graphical abstract

Figure 1.

Changes in systolic blood pressure from enrollment to 24 h according to cut-off infarct volume of 50 ml. The mean between-management difference in systolic blood pressure over 24 h was: Infarct volume ⩽50 ml: 6.29 mmHg (95% CI, 1.67–10.91; p = 0.008, (a)). Infarct volume >50 ml: 17.07 mmHg (95% CI, 8.50–25.63; p < 0.001, (b)).

Figure 2.

Distributions of modified Rankin Scale scores at 3 months according to the BP managements stratified by cut-off infarct volume of 50 ml. aOR: adjusted odds ratio; BP: blood pressure; mRS: modified Rankin Scale.

Figure 3.

Functional outcome association of the blood pressure management with infarct volumes. The regression curve and confidence region from a logistic regression analysis estimate the probability of achieving functional independence at 3 months (mRS score 0–2) based on infarct volume and BP management with interactions. Predicted probabilities are shown from a regression model adjusted for age, sex, onset-to-randomization time, infarct volume, NIHSS score > 15 before EVT, and BP management, including interaction between infarct volume and BP management. Cut-off values were determined by the crossing point of the regression lines. BP: blood pressure; EVT: endovascular thrombectomy; mRS: modified Rankin Scale; NIHSS: National Institutes of Health Stroke Scale.