Intensive Versus Conventional Blood Pressure Lowering After Successful Endovascular Thrombectomy: OPTIMAL-BP 1-Year Outcomes

Bottom line

In this 1-year extension of OPTIMAL-BP, intensive systolic BP lowering (<140 mmHg) after successful endovascular thrombectomy reperfusion resulted in worse functional independence at 1 year than conventional management (140-180 mmHg), with no between-group difference in 1-year mortality or mRS trajectory, durable findings that support current recommendations against intensive BP lowering in the first 24 hours after successful thrombectomy.

PICO at a glance

• Population: Adults with large-vessel-occlusion acute ischemic stroke who achieved successful reperfusion (TICI 2b/3) after endovascular thrombectomy and had systolic BP 140 mmHg or higher on 2 readings 2 minutes apart within 2 hours post-recanalization (306 randomized; 294 completed 1-year follow-up).
• Intervention or exposure: Intensive BP management, systolic BP target below 140 mmHg for 24 hours, titrated with labetalol and nicardipine, goal BP intended within 60 minutes of randomization.
• Comparator: Conventional BP management, systolic BP target 140-180 mmHg for 24 hours, same titration agents.
• Outcomes: Co-primary outcomes at 1 year, functional independence (modified Rankin Scale 0-2) and all-cause mortality, via multivariable logistic regression adjusting for age, sex, onset-to-randomization time, and baseline NIH Stroke Scale.
• Study design: OPTIMAL-BP, a phase 3, multicenter, prospective, open-label, blinded-endpoint (PROBE-design) randomized controlled trial at 19 centers in South Korea.

Clinical question and design

Endovascular thrombectomy (EVT) has transformed acute ischemic stroke care, but blood pressure management in the hours after successful reperfusion remains unsettled. The original OPTIMAL-BP trial already showed short-term harm from intensive BP lowering after recanalization. This 1-year extension asks whether that harm was a transient, treatment-window artifact, or a durable signal that should shape how aggressively clinicians titrate BP after successful thrombectomy.

Patients who underwent EVT, achieved successful reperfusion (TICI 2b/3), and had systolic BP of at least 140 mmHg on 2 measurements 2 minutes apart within 2 hours after recanalization were randomized 1:1 to intensive or conventional BP management for 24 hours after enrollment. Among 306 randomized patients, 294 (96.1%) completed 1-year follow-up.

Intervention and outcomes measured

Per the registered protocol (ClinicalTrials.gov NCT04205305), both arms were titrated using labetalol and nicardipine, with the goal BP intended to be reached within 60 minutes of randomization. Only the target differed, below 140 mmHg (intensive) versus 140-180 mmHg (conventional) systolic, not the drugs used. Co-primary outcomes at 1 year were functional independence (mRS 0-2) and all-cause mortality, estimated via multivariable logistic regression adjusted for age, sex, onset-to-randomization time, and baseline NIHSS.

Results

In the intention-to-treat analysis, functional independence at 1 year was numerically lower with intensive BP management: 40.5% versus 52.7% (adjusted OR, 0.59; 95% CI, 0.34-1.00; P=0.051), narrowly missing the conventional P<0.05 threshold. The per-protocol analysis showed a consistent, statistically significant effect: 41.1% versus 54.7% (adjusted OR, 0.56; 95% CI, 0.32-0.97; P=0.040).

Safety and additional findings

One-year mortality and the distribution of mRS changes from 3 months to 1 year did not differ between groups. Stable 1-year mortality and mRS-trajectory findings suggest the functional-outcome harm in the intensive arm is not offset by a survival or later-recovery advantage.

Uncertainty and limitations

This was a single-country (South Korea) trial population, which may limit generalizability to other health systems and BP-management protocols. The intention-to-treat primary comparison did not reach the conventional P<0.05 threshold (P=0.051). Open-label treatment assignment (only outcome assessment was blinded) introduces potential for differential post-randomization care.

Literature review and evidence synthesis

This 1-year OPTIMAL-BP report sits within an active evidence base on post-thrombectomy BP targets. A 2026 Cochrane systematic review on blood pressure management in reperfused ischemic stroke and a 2026 meta-analysis of randomized trials comparing intensive versus standard BP control after endovascular thrombectomy both directly synthesize this same treatment question across trials including OPTIMAL-BP. A 2022 individual-patient-data meta-analysis in Neurology examined blood pressure after thrombectomy and outcomes across observational and trial cohorts, providing the pre-OPTIMAL-BP evidence context this randomized 1-year extension now updates.

How this fits with the broader evidence

This 1-year extension closes an important gap left by the original OPTIMAL-BP trial's short-term readout: the direction and approximate magnitude of harm from intensive post-thrombectomy BP lowering persisted at 1 year rather than attenuating. The per-protocol analysis, arguably the more clinically relevant comparison, since it reflects patients who actually received the assigned BP target, reached significance with a similar effect size to the intention-to-treat estimate. Pharmacists managing post-thrombectomy BP protocols should recognize labetalol and nicardipine as the shared titration agents, and the 60-minute target-achievement window as a benchmark relevant to order-set design and nursing-driven titration protocols. Overshoot below 140 mmHg systolic in the first 24 hours after successful reperfusion is not a benign, transient overtreatment, it is associated with worse functional outcomes a year later.

ACPE UAN: 0683-0000-26-036-H01-P

---

Study source: PMID:42212393