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

IntroductionThere 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.Methods218 patients were randomized within 12h of AIS to maintain the SBP during 24h within three ranges: Group 1 140-160mmHg, Group 2 161-180mmHg or Group 3 181-200mmHg. Vasoactive drugs and fluids were used to achieve these targets. Good outcome was defined as a modified Rankin score 0-2 at 90-days.ResultsThe median SBP in the three groups in 24h was: 153mmHg, 163mmHg, and 178mmHg, 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 24h. 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).ConclusionsGood outcome in 90days 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 161-180mmHg). SICH occurred more frequently in Group 3 (181-200mmHg).