Response by Powers and Rabinstein to Letter Regarding Article, "2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association".

HomeStrokeVol. 50, No. 9Response by Powers and Rabinstein to Letter Regarding Article, "2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association" Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBResponse by Powers and Rabinstein to Letter Regarding Article, "2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association" William J. Powers, MD, Chair Alejandro A. Rabinstein, MD, Co-Chair William J. PowersWilliam J. Powers University of North Carolina, Chapel Hill Alejandro A. RabinsteinAlejandro A. Rabinstein Mayo Clinic, Rochester, MN, On behalf of the Writing Group for the American Heart Association/American Stroke Association 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Originally published8 Aug 2019https://doi.org/10.1161/STROKEAHA.119.026917Stroke. 2019;50:e277–e278Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: August 8, 2019: Ahead of Print In Response:We thank Drs Mulder, Lingsma, and Dippel for their interest in the "2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke." We agree that there are no data concerning benefit and safety of mechanical thrombectomy in patients with blood pressure >185/110 mm Hg, since most randomized clinical trials that demonstrated benefit of mechanical thrombectomy, including DEFUSE-3 (Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution-3), excluded patients with a blood pressure >185/110 mm Hg.1,2 In the MR CLEAN study (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) referred to, there were only 4 patients with blood pressure >185/110 mm Hg, and only 8 patients who received antihypertensive treatment to reduce their blood pressure to <185/110 mm Hg.3 The lack of association between baseline blood pressure and benefit of mechanical thrombectomy in this study does not provide data on the benefit of treatment nor the risks of lowering blood pressure in patients with blood pressure >185/110 mm Hg who undergo mechanical thrombectomy. However, the lack of definitive data does not change the fact that clinicians will be faced with this situation and have to make treatment decisions from other evidence. American Heart Association Guideline recommendations are based on an assessment of benefit versus risk.4 We do know the magnitude of the benefit of mechanical thrombectomy in patients primarily with blood pressure <185/110 mm Hg.1 We also do know that there is little if any risk to treating hypertension in acute ischemic stroke in general. The concept that autoregulation is impaired, and that lowering blood pressure will reduce cerebral blood flow to critically perfused area was derived from intracarotid injection cerebral blood flow studies performed in 1960s. This concept has not been replicated by more recent studies using cerebral blood flow techniques with better spatial resolution.5,6 Randomized clinical trials and observational studies have failed to show any deleterious effect of rapidly treating hypertension in acute ischemic stroke in those not receiving intravenous alteplase.1,7 The International Stroke Trial enrolled patients with blood pressures up to 220/130 mm Hg. Those who received blood pressure lowering medications had better early and late clinical outcomes than those who did not, including, the subgroup of patients with large vessel occlusion manifested by a hyperdense middle cerebral artery sign.8 Therefore, we must disagree with Drs Mulder, Lingsma, and Dippel that "the available data provides no rationale for a blood pressure threshold." We do know the magnitude of the benefit of mechanical thrombectomy in patients with blood pressure <185/110 mm Hg. We do know that the risk of treating hypertension in acute ischemic stroke is low. A Class (Strength) of Recommendation IIa indicates that benefit is greater that the risk.4 A clear benefit of mechanical thrombectomy in patients with blood pressure <185/110 mm Hg with a low risk of treating high blood pressures supports a Class IIa recommendation for reducing blood pressure to this level before mechanical thrombectomy. This is not a Class I recommendation based on definitive randomized clinical trial data directing that patients with blood pressure >185/110 mm Hg should be acutely treated with blood pressure lowering drugs until blood pressure reaches ≤185/110, or that mechanical thrombectomy should be withheld in these patients. This Class IIa recommendation provides guidance based on the best available evidence that "it is reasonable to maintain blood pressure ≤185/110 mm Hg before the procedure." Furthermore, for the reasons raised by Mulder et al3 and because blood pressure management is something that is important for every patient who undergoes mechanical thrombectomy, this topic deserves further investigation.William J. Powers, MD, ChairUniversity of North CarolinaChapel HillAlejandro A. Rabinstein, MD, Co-ChairMayo ClinicRochester, MNOn behalf of the Writing Group for the American Heart Association/American Stroke Association 2018 Guidelines for the Early Management of Patients With Acute Ischemic StrokeDisclosuresDr Powers received NIH research grant. The other author reports no conflict.FootnotesStroke welcomes Letters to the Editor and will publish them, if suitable, as space permits. Letters must reference a Stroke published-ahead-of-print article or an article printed within the past 4 weeks. The maximum length is 750 words including no more than 5 references and 3 authors. Please submit letters typed double-spaced. Letters may be shortened or edited.Guest Editor for this article was James C. Grotta, MDReferences1. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al; American Heart Association Stroke Council. 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.Stroke. 2018; 49:e46–e110. doi: 10.1161/STR.0000000000000158LinkGoogle Scholar2. Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, et al; DEFUSE 3 Investigators. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging.N Engl J Med. 2018; 378:708–718. doi: 10.1056/NEJMoa1713973CrossrefMedlineGoogle Scholar3. Mulder MJHL, Ergezen S, Lingsma HF, Berkhemer OA, Fransen PSS, Beumer D, et al; Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands (MR CLEAN) Investigators. Baseline blood pressure effect on the benefit and safety of intra-arterial treatment in MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands).Stroke. 2017; 48:1869–1876. doi: 10.1161/STROKEAHA.116.016225LinkGoogle Scholar4. Halperin JL, Levine GN, Al-Khatib SM, Birtcher KK, Bozkurt B, Brindis RG, et al. Further evolution of the ACC/AHA clinical practice guideline recommendation classification system: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.Circulation. 2016; 133:1426–1428. doi: 10.1161/CIR.0000000000000312LinkGoogle Scholar5. Jordan JD, Powers WJ. Cerebral autoregulation and acute ischemic stroke.Am J Hypertens. 2012; 25:946–950. doi: 10.1038/ajh.2012.53CrossrefMedlineGoogle Scholar6. Sare GM, Gray LJ, Bath PM. Effect of antihypertensive agents on cerebral blood flow and flow velocity in acute ischaemic stroke: systematic review of controlled studies.J Hypertens. 2008; 26:1058–1064. doi: 10.1097/HJH.0b013e3282fbd240CrossrefMedlineGoogle Scholar7. Brott T, Lu M, Kothari R, Fagan SC, Frankel M, Grotta JC, et al. Hypertension and its treatment in the NINDS rt-PA Stroke Trial.Stroke. 1998; 29:1504–1509.LinkGoogle Scholar8. Berge E, Cohen G, Lindley RI, Sandercock P, Wardlaw JM, Sandset EC, et al. 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Wajngarten M and Silva G (2019) Hypertension and Stroke: Update on Treatment, European Cardiology Review, 10.15420/ecr.2019.11.1, 14:2, (111-115) Macha K, Hoelter P, Siedler G, Wang R, Knott M, Stoll S, Engelhorn T, Doerfler A, Schwab S, Mühlen I and Kallmünzer B (2021) IV-Thrombolysis in Ischemic Stroke With Unknown Time of Onset—Safety and Outcomes in Posterior vs. Anterior Circulation Stroke, Frontiers in Neurology, 10.3389/fneur.2021.692067, 12 September 2019Vol 50, Issue 9 Advertisement Article InformationMetrics © 2019 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.119.026917PMID: 31390963 Originally publishedAugust 8, 2019 PDF download Advertisement SubjectsIschemic Stroke