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Early Manipulation of Arterial Blood Pressure in Acute Ischemic Stroke (MAPAS): Results of a Randomized Controlled Trial

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A Letter to the Editor to this article was published on 22 April 2019

Abstract

Introduction

There is uncertainty over the optimal level of systolic blood pressure (SBP) in the setting of acute ischemic stroke (AIS). The aim of this study was to determine the efficacy of the early manipulation of SBP in non-thrombolised patients. The key hypothesis under investigation was that clinical outcomes vary across ranges of SBP in AIS.

Methods

218 patients were randomized within 12 h of AIS to maintain the SBP during 24 h within three ranges: Group 1 140–160 mmHg, Group 2 161–180 mmHg or Group 3 181–200 mmHg. Vasoactive drugs and fluids were used to achieve these targets. Good outcome was defined as a modified Rankin score 0–2 at 90-days.

Results

The median SBP in the three groups in 24 h was: 153 mmHg, 163 mmHg, and 178 mmHg, respectively, P < 0.0001. Good clinical outcome did not differ among the different groups (51% vs 52% vs 39%, P = 0.27). Symptomatic intracranial hemorrhage (SICH) was more frequent in the higher SBP range (1% vs 2.7% vs 9.1%, P = 0.048) with similar mortality rates. No patient had acute neurological deterioration related to the SBP reduction in the first 24 h. In our logistic regression analysis, the odds of having good clinical outcome was higher in Group 2 (OR 2.83) after adjusting for important confounders. Regardless of the assigned group, the probability of good outcome was 47% in patients who were manipulated to increase the BP, 42% to decrease and 62% in non-manipulated (P = 0.1). Adverse effects were limited to Group 2 (4%) and Group 3 (7.6%) and were associated with the use of norepinephrine (P = 0.05).

Conclusions

Good outcome in 90 days was not significantly different among the 3 blood pressure ranges. After logistic regression analysis, the odds of having good outcome was greater in Group 2 (SBP 161–180 mmHg). SICH occurred more frequently in Group 3 (181–200 mmHg).

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Acknowledgements

We thank Magda Martins for the continuous support to finish this study.

Funding

This research was supported by Hospital de Clínicas de Porto Alegre and CAPES. The study was designed, conducted, analyzed and interpreted by the investigators independent of sponsors.

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Authors and Affiliations

  1. Vascular Unit, Emergency Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Ramiro Barcelos 2350, Porto Alegre, RS, CEP 90 035-903, Brazil

    Luiz Antonio Nasi, Sheila Cristina Ouriques Martins, Gustavo Weiss, Andrea Garcia de Almeida, Rosane Brondani, Letícia Costa Rebello, Angélica DalPizzol, Maria Júlia Monteiro Valença, Letícia F. Wirth & Gerson Nunes

  2. Stroke Division, Neurology Service, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil

    Sheila Cristina Ouriques Martins, Gustavo Weiss, Andrea Garcia de Almeida, Rosane Brondani, Letícia Costa Rebello, Angélica DalPizzol & Maria Júlia Monteiro Valença

  3. Hypertension Group, Cardiology Service, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil

    Miguel Gus & Flávio Danni Fuchs

  4. The George Institute for Global Health, Royal Prince Alfred Hospital, University of New South Wales, Sydney, Australia

    Craig S. Anderson

Authors
  1. Luiz Antonio Nasi
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  2. Sheila Cristina Ouriques Martins
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  3. Miguel Gus
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  4. Gustavo Weiss
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  7. Letícia Costa Rebello
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  11. Letícia F. Wirth
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  12. Gerson Nunes
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  13. Craig S. Anderson
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Contributions

LAN planned the study, interpreted the data and wrote the first draft of the report. SCOM planned and supervised the study, interpreted the data and wrote the report. MG planned the study, interpreted the data and wrote the report. GW, AGA, RB, LCR, ADP, MJMV, LFW and GN contributed to the report. FDN reviewed and contributed to the report. CSA interpreted the data and wrote the report.

Corresponding author

Correspondence to Luiz Antonio Nasi.

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Conflict of interest

C.S.A reports membership of Advisory Boards for Pfizer and The Medicines Company, and receiving travel reimbursement and honorarium from Takeda China and Covidien. The other authors declare no potential conflict of interest.

Ethical Approval

The study was approved by the Ethical Committee of Hospital de Clínicas de Porto Alegre. All patients (or close relative) provided informed consent.

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Nasi, L.A., Martins, S.C.O., Gus, M. et al. Early Manipulation of Arterial Blood Pressure in Acute Ischemic Stroke (MAPAS): Results of a Randomized Controlled Trial. Neurocrit Care 30, 372–379 (2019). https://doi.org/10.1007/s12028-018-0642-5

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