Response by Mistry to Letter Regarding Article, “Blood Pressure after Endovascular Therapy for Ischemic Stroke (BEST): A Multicenter Prospective Cohort Study

To the Editor,

We greatly appreciate interest in our article by Anadani et al. The Blood Pressure after Endovascular Stroke Therapy (BEST) was designed as a prospective, multi-institutional study with a prespecified hypothesis and analysis plan to identify a data-driven target of peak systolic blood pressure (SBP) after endovascular therapy that best dichotomizes good functional outcomes from bad.¹ We intentionally did not supervise our analysis to generate a perceivably feasible SBP target for a future randomized trial.

The results of the BEST study are strengthened by reduction of the biases inherent to prior retrospective studies as well as protocolized data collection with centralized data monitoring. Our results are consistent with prior studies^2–4 that have found a similar peak SBP target that best associated with worse functional outcomes. We appreciate the attempt by Anadani et al. to validate our findings in their large retrospective cohort. Their target of 169.5 mmHg may also be considered for testing in future clinical trials. However, this target will also be a subject to the same limitation- lack of separation between observed/achieved interventional SBP values and the standard-of-care SBP value (180 mmHg)- as the Anadani et al. have rightly suggested. The target generated in the BEST study informs the selection of a peak SBP goal for testing in future clinical trials. In the BEST study, a “U” shape relationship between peak SBP and 90-day functional outcome was not identified. Thus, lower targets of peak SBP could be employed in such future clinical trial at the investigator’s discretion, while accounting for the potentially harmful effects (i.e., worsening of infarct volume and functional outcomes) of induced relative hypotension.