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What’s the BEST Target SBP Post-Embolectomy for Stroke?

October 12, 2023

Written by Millie Cossé

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More aggressive systolic blood pressure (SBP) goals, beyond keeping it <180 mmHg, probably don’t make much of a difference in outcomes for patients who have undergone endovascular therapy for ischemic stroke.

Stroke management at its BEST
The AHA recommends keeping the SBP <180 mmHg post-embolectomy. This randomized, blinded futility clinical trial of 120 patients aimed to examine potential futility of lower systolic blood pressure (SBP) targets after endovascular therapy for ischemic stroke. Patients were randomized to SBP goals of <140 mmHg, <160 mmHg, or ≤180 mmHg. Primary endpoints were follow-up infarct volume at 36 hours and modified Rankin Scale.

This study is a futility trial, meaning that the endpoints were assessed for likelihood that a future clinical trial with a maximum sample size of 1,500 patients would have a >25% chance of pivotal results or if there was unequivocal harm with lower SBP targets.  In this case, the results do not definitively suggest that lower SBP targets would be futile; however, the authors argue that these results should “dampen enthusiasm” for future research into the topic given the very low likelihood that lower SBP targets would improve patient outcomes after endovascular treatment for ischemic stroke.

How will this change my practice?
While I may not ever be personally responsible for the inpatient management of post-embolectomy stroke patients, these results might help reassure some of our critical care readers that higher post-embolectomy SBP goals are unlikely to be causing harm.

Editor’s note: As it turns out, the OPTIMAL-BP RCT was published alongside BEST-II. OPTIMAL-BP found that lowering the SBP <140 mmHg in the first 24 hours post-embolectomy was harmful. The best evidence seems to be to keep SBP between 140-180 mmHg. ~Clay Smith

Blood Pressure Management After Endovascular Therapy for Acute Ischemic Stroke: The BEST-II Randomized Clinical Trial. JAMA. 2023 Sep 5;330(9):821-831. doi: 10.1001/jama.2023.14330.