March 11, 2021

BP-TARGET Investigates Benefit of Intense Blood Pressure Lowering After Endovascular Therapy for Stroke

March 11, 2021—Data from the BP-TARGET suggest a strategy of intensive systolic blood pressure (SBP) lowering after successful endovascular therapy in adults with an acute ischemic stroke may not improve the rate of radiographic intraparenchymal hemorrhage at 24 to 36 hours compared with a standard blood pressure target.

Key Findings

The primary outcome of radiographic intraparenchymal hemorrhage on CT at 24 to 36 hours occurred in 65/154 (42%) patients in the intensive SBP target group and 68/157 (43%) patients in the standard target group (adjusted odds ratio, 0.96; 95% CI, 0.60-1.51; P = .84).
An intensive SBP-lowering strategy to 100 to 129 mm Hg after endovascular therapy is not supported for the reduction of radiographic intraparenchymal hemorrhage rates.
BP-TARGET data are not in accordance with previous observational studies that have associated elevated SBP and worse functional outcomes.

Professor Mikael Mazighi, MD, et al published the findings in The Lancet Neurology. The multicenter, open-label BP-TARGET randomized controlled trial was conducted at four academic hospital centers in France. Eligible patients were adults (age ≥ 18 years) with an acute ischemic stroke caused by a large vessel occlusion that was successfully treated with endovascular therapy.

A total of 318 patients were included in the intention-to-treat analysis. Patients were randomly assigned (1:1) to either an intensive SBP target group (100-129 mm Hg) or a standard care SBP target group (130-185 mm Hg) within the first hour after reperfusion. Randomization was achieved via a central web-based procedure, stratified by center and intravenous thrombolysis use before endovascular therapy. In both groups, the target SBP had to be achieved within 1 hour after randomization and maintained for 24 hours with intravenous blood pressure–lowering treatments.

The rate of radiographic intraparenchymal hemorrhage at 24 to 36 hours as seen on CT scan, which was the primary outcome, occurred in 65 of 154 (42%) patients in the SBP target group and 68 of 157 (43%) in the standard SBP target group (adjusted odds ratio, 0.96; 95% CI, 0.60-1.51; P = .84).

The investigators also reported the mean SBP during the first 24 hours after reperfusion was 128 mm Hg (SD, 11) in the intensive target group and 138 mm Hg (SD, 17) in the standard target group. The median percentage time spent in the assigned target range of SBP was 61% (interquartile range [IQR], 47.7%-76.2%) in the intensive target group and 66.6% (IQR, 32.5%-88.6%) in the standard target group.

Among safety endpoints, hypotensive events were not significantly different between both groups and occurred in 12 of 158 (8%) patients in the intensive target group and five of 160 (3%) in the standard target group. Mortality within the first week after randomization occurred in 11 of 158 (7%) patients in the intensive target group and in seven of 160 (4%) in the standard target group.

ENDOVASCULAR TODAY ASKS….

We asked lead author Prof. Mikael Mazighi, MD, with Rothschild Foundation Hospital in Paris, France, to discuss the results further:

In light of these data and your experience in this trial, how will you adjust your treatment algorithm for blood pressure management in patients with acute ischemic stroke?

It is possible that a one-size-fits-all approach with a similar blood pressure target for every patient is not suitable. A more tailored blood pressure management probably makes more sense for patients with different comorbidities (eg, a young patient with arterial dissection versus an older one with a history of chronic hypertension). From this perspective, guided blood pressure management by hemodynamic parameters (eg, limitation of blood pressure variability) need to be evaluated to assess if the latter approach is relevant or not, and determine if blood pressure is only a marker of the severity of the disease.

How would you summarize the disparity between the findings of the BP-TARGET study and previous observational studies that suggested an association between elevated SBP and worse outcomes for stroke?

Several points may be raised. First, from a methodologic perspective, it is not the first time that a randomized study will bring different results than previous observational studies, due to their inherent limitations.

Second, the BP-TARGET study was conducted in French stroke centers with specific blood pressure managements (ie, predominant use of nicardipine for blood pressure lowering agents, noninvasive and noncontinuous blood pressure monitoring), which may have impacted significantly the findings as compared with other countries where blood pressure is invasively monitored.

Finally, blood pressure management in the BP-TARGET study was driven by the target of the allocated arm and not by the quality of the endovascular reperfusion. In some situations, when reperfusion is not complete (ie, TICI 2b), stroke physicians may have a more permissive approach with a less intensive blood pressure reduction (eg, to avoid worsening of infarct volume in the remained hypoperfused territories). The latter situation may be responsible of some biases in observational studies.

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