Blood Pressure Management after Mechanical Thrombectomy for Acute Ischemic Stroke: A Survey of the StrokeNet Sites

Background

It is unclear what factors providers take into account to determine the target blood pressure (BP) after mechanical thrombectomy (MT) in patients who had acute ischemic stroke. We aimed to understand practice patterns of post-MT BP management across institutions in the United States.

Methods

We surveyed StrokeNet institutions providing MT and post-MT care with an online questionnaire, designed to understand institutional post-MT BP management practices.

Results

Of 131 potential institutions, 58 completed the survey. The majority of institutions target systolic BP (SBP, n = 53, 91%) during the first 24 hours post-MT (n = 32, 55%) using nicardipine as a first-line agent (n = 43, 74%). At most institutions, BP management is determined by a team of physicians in a collaborative fashion (n = 30, 52%) and individualized on a case-by-case basis (n = 39, 67%) after taking the reperfusion status into account (n = 42, 72%). In patients with successful reperfusion, 36% (n = 21) of the institutions target SBP in the range of 120-139 mm Hg, 21% (n = 12) target 140-159 mm Hg, and 28% (n = 16) would accept any value less than or equal to 180 mm Hg. In patients with unsuccessful reperfusion, 43% (n = 25) would accept any SBP value less than or equal to 180 mm Hg and 10% (n = 6) would target SBP less than or equal to 220 mm Hg.

Conclusions

We found that majority of the institutions do not have a standardized protocol for post-MT BP management. There was interinstitutional heterogeneity in the preferred target of SBP post-MT and most institutions target values of SBP lower than 180 mm Hg in post-MT patients. Prospective data and randomized control trial are needed to identify the optimal target BP.

Introduction

Based on several randomized clinical trials,¹ the 2015 update to the American Heart Association/American Stroke Association (AHA/ASA) early stroke management guidelines suggest treating patients with acute large vessel ischemic stroke (AIS) with mechanical thrombectomy (MT) within 6 hours of stroke onset.² However, these guidelines do not provide updated recommendations on post-MT blood pressure (BP) management in these patients. The 2018 AHA/ASA guidelines recommend treating systolic blood pressure (SBP) above 180 mm Hg in patients undergoing any form of reperfusion therapy.³ In our experience, there is little consensus among the stroke physicians regarding preferred post-MT BP target and its duration. Moreover, whether this target should be dictated by angiographic revascularization status is unclear. Therefore, we surveyed physicians at various institutions across the United States to determine practice patterns of post-MT BP management in patients with AIS.