Blood Pressure Management After Endovascular Therapy: An Ongoing Debate.
Blood Pressure Management After Endovascular Therapy: An Ongoing Debate.
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DOI：
10.1161/strokeaha.121.034995
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发表时间：
2021-06
期刊：
影响因子：
8.3
通讯作者：
Anderson CS
中科院分区：
文献类型：
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作者：
Anadani M;de Havenon A;Mistry E;Anderson CS
(AIS)是复杂的问题，取决于各种因素，如血管闭塞的部位、脑缺血的程度和患者的合并症。1自2015年发表了多项血管内治疗（EVT）的积极临床试验以及随后EVT的广泛应用以来，降血压治疗因其减轻再灌注损伤的潜力而引起关注。1尽管观察性研究一致表明再灌注后血压升高与不良结局之间存在密切联系，2，3在荟萃分析中进一步加强，4 AIS后改变血压的益处尚未得到证实。AIS后高血压可能只是神经系统严重程度、基础慢性高血压或其他与不良结局相关的共病因素的标志物，5迄今为止AIS随机试验的中性结果进一步加强了这一点。6，7 2019年美国心脏协会/美国卒中协会指南建议EVT后的BP目标为180/105，作为静脉溶栓文献的合理外推。8然而，这可能不适合接受EVT的AIS患者，这一点从美国医疗服务提供者对这些建议的不同采纳情况中可以看出9;并强调需要更多的随机对照试验来评估强化降压（或增强）在这一重要患者群体中的疗效和安全性。BP TARGET（急性卒中中降低血管内治疗后出血的血压目标）是在法国进行的第一项此类多中心临床试验，该试验采用前瞻性、随机、开盲终点设计，旨在评价强化收缩压（SBP）降低对EVT后成功再灌注（脑缺血改良治疗2b-3）后结局的影响。将10例合格的前循环近端血管闭塞（颅内颈动脉或近端大脑中动脉[M1]，或两者）导致AIS且在EVT结束时成功再灌注后SBP≥ 130 mm Hg的成人患者随机分配至标准（130-185 mm Hg）或强化（100-129 mm Hg）SBP目标组，在1小时内实现。该研究入组了324例患者（每组162例），其中236例（74%）患有孤立性大脑中动脉闭塞，172例（54%）在手术结束时实现完全再灌注（脑缺血改良治疗3）。
(AIS) are complex issues, dependent upon various factors, such as the site of vessel occlusion, extent of cerebral ischemia, and patient comorbidities. 1 Since multiple positive clinical trials of endovascular therapy (EVT) were published in 2015, and subsequent wide utilization of EVT, BP-lowering treatment has attracted attention for its potential in mitigating reperfusion injury. 1 Although observational studies are consistent in demonstrating a strong link between elevated BP after reperfusion and poor outcome, 2, 3 further reinforced in meta-analysis, 4 the benefits of altering BP after AIS has yet to be proven. Post-AIS hypertension may simply be a marker of neurological severity, underlying chronic hypertension, or other comorbid factors related to poor outcome, 5 further reinforced by the neutral results of randomized trials in AIS to date. 6, 7 The 2019 American Heart Association/American Stroke Association guidelines recommended a BP goal of 180/105 after EVT, as a reasonable extrapolation from the intravenous thrombolysis literature. 8 However, this may not be appropriate for patients with AIS receiving EVT, as evident by the variable adoption of these recommendations by providers in the United States9; and emphasizing the need for more randomized controlled trials to assess the efficacy and safety of intensive BP lowering (or enhancement) in this important patient group. The BP TARGET (Blood Pressure Target in Acute Stroke to Reduce Hemorrhage After EndovascularTherapy) is the first such multicenter clinical trial conducted in France, which has a prospective randomized open blinded end point design to evaluate the impact of intensive systolic BP (SBP) reduction on outcomes after successful post-EVT reperfusion (modified treatment in cerebral ischemia 2b–3). 10 Eligible adult patients with AIS from proximal vessel occlusion of the anterior circulation (intracranial carotid or proximal middle [M1] cerebral arteries, or both) with SBP≥ 130 mm Hg after successful reperfusion at the end of EVT were randomly assigned to standard (130–185 mm Hg) or intensive (100–129 mm Hg) SBP targets, to be achieved within 1 hour. The study enrolled 324 patients (162 in each arm), including 236 (74%) with isolated middle cerebral artery occlusion and 172 (54%) achieving complete reperfusion (modified treatment in cerebral ischemia 3) at the end of procedure.