Abstract Background and aims The prognostic impact of intensive blood pressure (BP) reduction after endovascular thrombectomy (EVT) may vary according to baseline systolic BP. This study evaluated whether baseline BP before EVT modifies the effect of intensive versus conventional BP management on outcomes after successful reperfusion. Methods This was a prespecified subgroup analysis of the OPTIMAL-BP randomized trial (NCT04205305), which compared intensive (SBP target 140 mm Hg) with conventional (140–180 mm Hg) BP control during the first 24 h after EVT. Patients were categorized by baseline SBP before EVT into low (140 mm Hg), intermediate (140–180 mm Hg), and high (180 mm Hg) groups (Fig. 1). Oucomes included functional independence at 3 months (mRS 0–2), symptomatic intracerebral hemorrhage (sICH) and stroke-related death within 3 months. Results Among 302 patients, intensive BP management significantly reduced the rate of functional independence in the intermediate BP group (40.5% vs 54.8%; adjusted OR 0.47, 95% CI 0.22–0.95; p = 0.039) (Table 1). No significant differences were observed in the low or high BP groups. Rates of sICH and 3-month mortality were similar across groups. A spline model demonstrated significant harm of intensive BP lowering above 160 mm Hg (adjusted p = 0.021). Conclusions Intensive BP lowering after EVT was associated with worse functional outcomes among patients with intermediate baseline SBP (140–180 mm Hg) before the procedure, without clear safety benefit. These findings suggest that aggressive BP reduction should be avoided in patients with moderately elevated baseline SBP after successful EVT. Conflict of interest IL HYUNG LEE. nothing to disclose Figure 1 - belongs to Methods Table 1 - belongs to Results
Lee et al. (2026) studied this question.