Blood Pressure Management After Endovascular Therapy for Acute Ischemic Stroke: The BEST-II Randomized Clinical Trial

Mistry, EA; Hart, KW; Davis, LT; Gao, Y; Prestigiacomo, CJ; Mittal, S; Mehta, T; LaFever, H; Harker, P; Wilson-Perez, HE; Beasley, KA; Krothapalli, N; Lippincott, E; Stefek, H; Froehler, M; Chitale, R; Fusco, M; Grossman, A; Shirani, P; Smith, M; Jaffa, MN; Yeatts, SD; Albers, GW; Wanderer, JP; Tolles, J; Lindsell, CJ; Lewis, RJ; Bernard, GR; Khatri, P

doi:10.1001/jama.2023.14330

Neuroanesthesia & neurocritical care

Blood Pressure Management After Endovascular Therapy for Acute Ischemic Stroke: The BEST-II Randomized Clinical Trial

JAMAPublished 5 Sep 2023Randomised controlled trial

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Authors' conclusion

Among patients with acute ischemic stroke, lower SBP targets less than either 140 mm Hg or 160 mm Hg after successful endovascular therapy did not meet prespecified criteria for futility compared with an SBP target of 180 mm Hg or less.

Study context

Population: Patients with acute ischemic stroke after successful endovascular therapy, 3 US comprehensive stroke centers, 2020–2022113 completed
Participants: 120 patients

Comparison: Lower systolic blood pressure (SBP) targets vs higher target after endovascular therapy
Primary endpoint: Multiple primary outcomes for futility: follow-up infarct volume at 36 (±12) hours and utility-weighted mRS score (0 worst to 1 best) at 90 (±14) days

Methodological detailsopen-label, blinded end point, phase 2, futility, multicentre

Open-label
Blinded end point
Phase 2
Futility
Multicentre

Primary result

As reported in the abstract

Follow-up infarct volume at 36 (±12) h; utility-weighted mRS score at 90 (±14) days

<140 mm Hg32.4mean · 95% CI 18.0 to 46.7 mL · mL

<160 mm Hg50.7mean · 95% CI 33.7 to 67.7 mL · mL

≤180 mm Hg46.4mean · 95% CI 24.5 to 68.2 mL · mL

Slope of follow-up infarct volume

−0.29

95% CI −0.81 to ∞futility P = .99

adjusted for baseline Alberta Stroke Program Early CT score

Slope of utility-weighted modified Rankin Scale (mRS) score

−0.0019

95% CI -∞ to 0.0017futility P = .93

adjusted for baseline utility-weighted mRS score

Predicted probability of success for a future trial, <140 mm Hg vs high target: 25%
Predicted probability of success for a future trial, 160 mm Hg vs high target: 14%

Further findings

Outcome	<140 mm Hg	<160 mm Hg
Predicted probability of success for a future trial vs high target	25%	14%

Predicted probability of success for a future trial vs high target: futility criterion: <25%

Reference

Authors: Mistry EA, Hart KW, Davis LT, Gao Y, Prestigiacomo CJ, Mittal S, et al.
All 29 authors
Mistry EA, Hart KW, Davis LT, Gao Y, Prestigiacomo CJ, Mittal S, Mehta T, LaFever H, Harker P, Wilson-Perez HE, Beasley KA, Krothapalli N, Lippincott E, Stefek H, Froehler M, Chitale R, Fusco M, Grossman A, Shirani P, Smith M, Jaffa MN, Yeatts SD, Albers GW, Wanderer JP, Tolles J, Lindsell CJ, Lewis RJ, Bernard GR, Khatri P
Journal: JAMA
Published: 5 Sep 2023
DOI: 10.1001/jama.2023.14330
PubMed: 37668620
Registration: NCT04116112

Topic: Neuroanesthesia & neurocritical care
Also indexed: Hemodynamics, fluids & transfusion

Intervention details

<140 mm Hg: SBP target 40 to less than 140 mm Hg for 24 hours
<160 mm Hg: SBP target 40 to less than 160 mm Hg for 24 hours
≤180 mm Hg: SBP target 40 to 180 mm Hg or less (guideline recommended) for 24 hours

Key notes

Lower SBP targets did not meet prespecified criteria for futility
1-sided α = .05

More notes

Harm-futility boundaries: 10-mL increase in infarct volume or 0.10 decrease in utility-weighted mRS per 20-mm Hg SBP target reduction

Original publication

Blood Pressure Management After Endovascular Therapy for Acute Ischemic Stroke: The BEST-II Randomized Clinical Trial. JAMA. Published 5 September 2023. doi:10.1001/jama.2023.14330

Read the original article ↗

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