Highlights
The 1-year extension of the randomized OPTIMAL-BP trial suggests that intensive post-thrombectomy blood pressure lowering to a systolic target of less than 140 mm Hg may have durable adverse effects on recovery.
Functional independence at 1 year was numerically lower with intensive blood pressure control in the intention-to-treat analysis and significantly lower in the per-protocol analysis.
All-cause mortality at 1 year did not differ between intensive and conventional management, suggesting the main signal relates to disability rather than survival.
These findings reinforce current practice patterns that avoid aggressive blood pressure reduction immediately after successful endovascular thrombectomy in patients with elevated post-reperfusion blood pressure.
Background
Blood pressure management after endovascular thrombectomy remains one of the most clinically important unresolved questions in acute ischemic stroke care. In patients with large vessel occlusion who achieve successful reperfusion, elevated blood pressure is common in the early post-procedural period. Clinicians have long faced a physiological dilemma: high blood pressure may increase the risk of reperfusion injury, cerebral edema, and hemorrhagic transformation, yet excessive lowering may reduce perfusion to vulnerable penumbral tissue or injured microvascular territories where autoregulation is impaired.
That tension has driven several trials of post-thrombectomy blood pressure targets. Early enthusiasm for tighter control was rooted in pathophysiologic plausibility and observational associations between elevated blood pressure and poorer outcomes. However, randomized data have not supported intensive lowering. Instead, they have raised concern that overly aggressive reduction soon after reperfusion may worsen neurological recovery.
The OPTIMAL-BP trial was an important contribution to this literature because it directly randomized patients with elevated systolic blood pressure after successful thrombectomy to either intensive or conventional management. The initial short-term findings suggested harm from intensive lowering. The critical question addressed by the current report is whether that early disadvantage persists, attenuates, or disappears over time. For clinicians, this matters because some treatment-related neurological deficits may reflect transient injury, whereas others may represent lasting impairment of recovery trajectories.
Study Design
Trial framework
OPTIMAL-BP (Outcome in Patients Treated With Intra-Arterial Thrombectomy-Optimal Blood Pressure Control) was a phase 3, multicenter, prospective, open-label, blinded end point, randomized controlled trial conducted at 19 centers throughout South Korea. The present report is a preplanned 1-year follow-up extension.
Population
Eligible patients had acute ischemic stroke due to large vessel occlusion, underwent endovascular thrombectomy, achieved successful reperfusion of the occluded artery, and had elevated blood pressure after recanalization. Specifically, enrollment required systolic blood pressure of at least 140 mm Hg on two measurements obtained 2 minutes apart within 2 hours after reperfusion.
This is an important selection criterion. The study does not address normotensive patients after thrombectomy, nor does it address patients with unsuccessful reperfusion. Its conclusions apply most directly to patients with elevated systolic blood pressure after technically successful endovascular treatment.
Interventions and comparator
Patients were randomly assigned to one of two 24-hour systolic blood pressure strategies after enrollment:
Intensive blood pressure management: target systolic blood pressure less than 140 mm Hg.
Conventional blood pressure management: target systolic blood pressure 140 to 180 mm Hg.
The contrast between these strategies reflects a clinically realistic choice. Conventional management approximates the upper ranges commonly tolerated in modern stroke care after reperfusion, whereas the intensive strategy tests the hypothesis that lower systolic pressure reduces reperfusion-related injury.
Outcomes
The primary outcomes for the 1-year extension were functional independence, defined as modified Rankin Scale (mRS) score 0 to 2 at 1 year, and all-cause mortality within 1 year. The modified Rankin Scale is the standard global disability measure used in stroke trials; scores of 0 to 2 generally reflect independence in daily activities.
The investigators also examined changes in mRS distribution between 3 months and 1 year. This is clinically useful because stroke recovery can continue beyond 90 days, especially in patients undergoing structured rehabilitation.
Statistical approach
Adjusted odds ratios were estimated using multivariable logistic regression with adjustment for age, sex, onset-to-randomization time, and baseline National Institutes of Health Stroke Scale (NIHSS) score. Both intention-to-treat and per-protocol analyses were reported. The inclusion of both approaches strengthens interpretability: intention-to-treat preserves the benefits of randomization, while per-protocol provides insight into the effect among patients who adhered more closely to the assigned strategy.
Key Findings
Follow-up completeness
Among 306 randomized patients, 294 completed the 1-year follow-up, for a retention rate of 96.1%. This is a major strength. Long-term stroke trials are often vulnerable to follow-up attrition, and such losses can bias outcome estimates if differential between groups. Here, follow-up was excellent.
Primary functional outcome at 1 year
In the intention-to-treat analysis, functional independence at 1 year occurred in 40.5% of patients assigned to intensive blood pressure lowering versus 52.7% assigned to conventional management. The adjusted odds ratio was 0.59 with a 95% confidence interval of 0.34 to 1.00, and the P value was 0.051.
Several points deserve emphasis. First, the absolute difference of roughly 12 percentage points is clinically meaningful. Second, the estimate consistently favored conventional treatment. Third, although the P value narrowly missed the conventional 0.05 threshold, the confidence interval reached the boundary of statistical significance and the effect direction aligns with prior short-term findings from the parent trial. In practice, this is not a reassuring neutral result; it is a near-significant signal of sustained harm.
The per-protocol analysis showed similar and statistically significant findings: functional independence at 1 year was 41.1% in the intensive group and 54.7% in the conventional group, with an adjusted odds ratio of 0.56 (95% confidence interval 0.32 to 0.97; P=0.040). The concordance between intention-to-treat and per-protocol analyses strengthens the inference that intensive blood pressure lowering may impair long-term recovery after thrombectomy.
Mortality
One-year all-cause mortality did not differ between groups. This is important because it indicates that the main effect of the intervention was not on survival, but on disability. From a patient-centered standpoint, that distinction matters greatly. Treatments that do not increase mortality can still have major implications if they increase dependence, institutional care needs, caregiver burden, and long-term rehabilitation costs.
Recovery trajectory from 3 months to 1 year
The distribution of modified Rankin Scale changes from 3 months to 1 year did not differ between groups. This suggests that the early disadvantage associated with intensive blood pressure lowering was not substantially reversed over time. In other words, the deficit appears durable rather than simply delayed recovery. That finding supports the concept that hemodynamic management in the immediate post-reperfusion phase may influence the biological course of brain recovery in ways that persist well beyond hospitalization.
Clinical Interpretation
Why might intensive lowering be harmful?
The most plausible mechanism is impaired perfusion of tissue that remains physiologically vulnerable despite angiographic reperfusion. Successful recanalization of a proximal vessel does not guarantee uniformly restored microcirculatory flow. Distal embolization, no-reflow phenomena, endothelial injury, blood-brain barrier disruption, edema, and disturbed autoregulation may all limit effective tissue reperfusion. In that setting, reducing systemic pressure too aggressively may lower cerebral perfusion pressure below a critical threshold in regions that are salvageable but unstable.
This explanation is consistent with modern understanding of stroke pathophysiology. The brain after ischemia is not hemodynamically uniform. Some areas may indeed be at risk from excessive pressure, but others may remain pressure-dependent. A single low systolic target for all successfully reperfused patients may therefore be too blunt an approach.
How should clinicians interpret the borderline P value?
The intention-to-treat result narrowly missed formal statistical significance, but it would be a mistake to interpret that as evidence of no effect. The point estimate, absolute difference, confidence interval, and per-protocol analysis all move in the same direction. In a trial context where prior short-term harm was already documented, this long-term follow-up is better viewed as reinforcing an existing signal rather than generating a new isolated observation.
For bedside decision-making, effect size and consistency may be more informative than a binary significant versus nonsignificant reading. A 12-point lower rate of independence at 1 year is clinically consequential even if the P value is 0.051 instead of 0.049.
Implications for guidelines and practice
The authors conclude that the findings support current recommendations against intensive blood pressure lowering after thrombectomy. That interpretation is well aligned with the broader randomized evidence base. While exact target ranges vary across institutions and guidelines, there is increasing caution against routine aggressive reduction to less than 140 mm Hg immediately after successful endovascular reperfusion, particularly in patients who were hypertensive enough to meet OPTIMAL-BP eligibility.
For clinicians in stroke units and neurocritical care settings, the practical message is straightforward: avoid reflexive early lowering of systolic blood pressure to below 140 mm Hg simply because recanalization has been achieved. Conventional management in the 140 to 180 mm Hg range appears safer with respect to long-term disability in this population.
Strengths and Limitations
Strengths
The study has several notable strengths. It is randomized, multicenter, and prospective, with blinded end point assessment. Follow-up completeness was excellent. The clinical question is directly relevant to a common post-thrombectomy management problem. Most importantly, the 1-year analysis addresses a gap often left unanswered by acute stroke trials, which commonly stop at 90 days.
Limitations
Several limitations should temper overgeneralization. First, the trial was open-label for treatment assignment, although blinded end point assessment reduces bias in outcome determination. Second, the total sample size was modest, which limits precision, especially for mortality and subgroup exploration. Third, the trial was conducted exclusively in South Korea, so external validity to other populations, practice environments, antihypertensive protocols, and post-stroke rehabilitation systems should be considered carefully.
Fourth, the results apply to patients with elevated systolic pressure after successful reperfusion, not to all thrombectomy-treated patients. Fifth, the report as summarized does not provide detailed mechanistic imaging correlates, such as infarct growth, edema burden, or hemorrhagic transformation patterns at long-term follow-up, which could help explain the observed disability difference. Finally, as with many blood pressure trials, achieved blood pressure profiles over time and treatment heterogeneity may influence interpretation beyond the nominal target assignment alone.
Context Within the Existing Literature
OPTIMAL-BP adds to a growing body of randomized evidence suggesting that lower is not necessarily better for blood pressure in the immediate period after thrombectomy. Observational studies initially linked elevated post-procedural blood pressure with worse outcomes, but such analyses are vulnerable to confounding by stroke severity, recanalization quality, and underlying autoregulatory failure. Randomized trials are more informative because they test whether intervention on blood pressure changes outcomes rather than merely tracks risk.
The current 1-year data are especially valuable because they indicate that early blood pressure management is not just associated with transient differences at 90 days. Instead, the treatment effect appears to shape durable functional status. This has implications for quality metrics, protocol design, and future precision medicine approaches to hemodynamic targets after reperfusion therapy.
The next frontier is likely individualized blood pressure management. Rather than a single universal target, future strategies may incorporate infarct core size, collateral status, reperfusion quality, hemorrhagic risk, baseline hypertension history, vessel territory, cerebral autoregulation monitoring, or perfusion imaging. Until such strategies are validated, the present data support avoiding intensive systolic targets below 140 mm Hg in the early post-thrombectomy window for patients resembling those enrolled in OPTIMAL-BP.
Practical Takeaways for Clinicians
After successful endovascular thrombectomy, elevated systolic blood pressure should not automatically trigger aggressive reduction to below 140 mm Hg.
In patients similar to those enrolled in OPTIMAL-BP, conventional management with a systolic target of 140 to 180 mm Hg for the first 24 hours appears more favorable for long-term independence.
When communicating with patients and families, it is reasonable to explain that blood pressure control after stroke must balance competing risks, and that excessively low early targets may reduce the brain’s ability to recover even after the blocked artery has been reopened.
Hospitals that still use routine intensive post-thrombectomy blood pressure protocols may wish to revisit these pathways in light of accumulating randomized evidence.
Conclusion
The 1-year extension of OPTIMAL-BP shows that intensive blood pressure lowering to a systolic target below 140 mm Hg after successful endovascular thrombectomy is associated with worse long-term functional recovery than conventional management. Mortality was unchanged, but disability outcomes favored the less aggressive strategy. These findings suggest that early hemodynamic decisions in the first 24 hours after reperfusion can have lasting consequences and support current recommendations against routine intensive blood pressure lowering in this setting.
Funding and Trial Registration
ClinicalTrials.gov identifier: NCT04205305.
Funding information was not provided in the source abstract supplied here. Readers should consult the full article for detailed funding and disclosure statements.
References
Jung JW, Kim YD, Heo J, Lee H, Kim BM, Kim DJ, Shin NY, Joo H, Yu S, Ahn SH, Sohn SI, Hong JH, Chang Y, Kim GS, Ok T, Lee JG, Chang JY, Seo JH, Lee S, Baek JH, Cho HJ, Yun J, Shin DH, Ha SH, Kim J, Yoo J, Baik M, Jung YH, Seo KD, Hwang YH, Park H, Kim CK, Kim JG, Lee IH, Choi JK, Jeon S, Lee HS, Kim KH, Kwon SU, Bang OY, Heo JH, Song TJ, Nam HS. Intensive Versus Conventional Blood Pressure Lowering After Successful Endovascular Thrombectomy: OPTIMAL-BP 1-Year Outcomes. Stroke. 2026-05-29. PMID: 42212393.
Nam HS, Kim YD, Heo J, Lee H, Kim BM, Kim DJ, et al. Outcome in Patients Treated With Intra-Arterial Thrombectomy-Optimal Blood Pressure Control (OPTIMAL-BP): primary randomized trial publication. Readers should consult PubMed/Stroke for full bibliographic details corresponding to the parent trial.
Powers WJ, Rabinstein AA, Ackerson T, et al. 2019 update to the 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. 2019;50:e344-e418.
European Stroke Organisation guidance documents and contemporary thrombectomy care statements should also be consulted for evolving recommendations on post-reperfusion blood pressure management.
