Abstract Body: IMPORTANCE: The impact of early blood pressure (BP) lowering in acute ischemic stroke patients with large vessel occlusion after successful endovascular thrombectomy (EVT) remains uncertain.

OBJECTIVE: To evaluate the safety and efficacy of BP lowering in patients with acute anterior circulation ischemic stroke who undergo EVT within 6 hours from onset and achieved successful recanalization.

METHODS: This study was a randomized, multicenter, open-label, blinded-endpoint clinical trial conducted from October 14, 2022, to March 18, 2024, with final follow-up on May 27, 2024. The trial took place at 63 stroke centers in China and included patients with acute anterior circulation ischemic stroke who underwent EVT within 6 hours of stroke onset and achieved successful recanalization (modified Thrombolysis in Cerebral Infarction score ≥ 2b). Participants were randomly assigned to either an intensive management group (systolic BP target <130 mm Hg) or a standard management group (systolic BP target <180 mm Hg). Blood pressure was reduced within one hour of randomization and maintained for 24 hours. The primary outcome was poor prognosis, defined as a modified Rankin Scale score of 3-6 at 90 days. A generalized linear model without any adjustment was used for the primary analysis.

RESULTS: This study was terminated early on March 18, 2024 based on safety concerns. A total of 383 patients were enrolled (Figure 1) (mean age, 72 years; 185 women [48.4%]; median baseline National Institute of Health Stroke Scale score 15). BP levels were significantly lower in the intensive group than in the standard group (Figure 2). Poor prognosis occurred in 130 (71.0%) patients in the intensive-management group and in 135 (67.5%) patients in the standard group (risk ratio, 1.05; 95% CI, 0.92-1.20; p=0.453). However, severe disability (modified Rankin Scale 4-5) was more common in the intensive group than in the standard group after adjustment (adjusted risk ratio, 1.45 [95% CI, 1.10-1.90], p=0.009) (Figure 3). There was no statistically significant difference in symptomatic intracerebral hemorrhage or all-cause death at 90 days between the two groups.

CONCLUSIONS: Intensive BP lowering to <130 mm Hg seems futile for outcomes improvement among patients with acute anterior circulation ischemic stroke who had successful EVT within 6 hours from onset. The precise BP management targets still require further investigation.

TRIAL REGISTRATION: chictr.org.cn identifier, ChiCTR2200057770