BP-TARGET AHT Substudy
Prestroke Antihypertensive Treatment Class and Outcomes After Successful Reperfusion in Large Vessel Occlusion Stroke
Clinical Question
Does the class of prestroke antihypertensive medication (RAS inhibitors vs non-RAS inhibitors) affect clinical outcomes and stroke severity after EVT in anterior circulation large vessel occlusion (LVO) stroke?
Bottom Line
In 203 hypertensive patients from BP-TARGET with LVO AIS post-EVT, prestroke non-RAS inhibitors (CCBs, diuretics) were associated with higher baseline NIHSS (+3.28 points; P=0.001) and 2.5x increased ICH risk (adjusted OR 2.48; P=0.025). RAS inhibitors (ACEi, ARBs, beta-blockers) were associated with lower NIHSS (-2.81; P=0.031) and no increased ICH. CCB use was independently associated with worse 3-month outcome (adjusted OR 0.42; P=0.044).
Major Points
- Post hoc analysis of BP TARGET RCT cohort evaluating impact of prestroke antihypertensive class on outcomes.
- RAS inhibitors included ACE inhibitors, ARBs, and beta-blockers; non-RAS included calcium channel blockers and diuretics.
- RAS inhibitor use associated with lower baseline NIHSS (−2.39 points; 95% CI −4.12 to −0.66) and better early neurological improvement (ΔNIHSS +3.28, p=0.001).
- Non-RAS inhibitor use was independently associated with higher risk of any ICH (OR 3.06; 95% CI 1.47–6.35, p=0.003).
- Favorable 90-day mRS (0–2) not significantly different between groups after adjustment (non-RAS vs RAS OR 0.59; 95% CI 0.30–1.17, p=0.13).
Design
Study Type: Post hoc observational analysis of a randomized controlled trial cohort (BP TARGET)
Randomization:
Blinding: Outcome adjudication was blinded; treatment group assignment was open-label in original BP TARGET RCT
Enrollment Period: BP TARGET enrollment: December 2016 – March 2020
Follow-up Duration: 90 days
Centers: 13
Countries: France
Sample Size: 203
Analysis: Multivariate regression adjusting for age, SBP, antihypertensive type, diabetes, stroke severity, etc.; ordinal logistic regression for mRS; NIHSS modeled continuously
Inclusion Criteria
- Acute ischemic stroke due to anterior circulation large vessel occlusion (ICA or M1)
- Underwent EVT with successful reperfusion (TICI 2b or 3)
- Documented use of antihypertensive medications prior to stroke
- Available 90-day mRS outcome
Exclusion Criteria
- No documented antihypertensive medication class
- Posterior circulation strokes
- Unsuccessful reperfusion
Arms
| Field | RAS inhibitors | Control |
|---|---|---|
| Intervention | Prestroke use of ACE inhibitors, ARBs, or beta-blockers | Prestroke use of calcium channel blockers or diuretics |
| Duration | Ongoing at time of stroke | Ongoing at time of stroke |
Outcomes
| Outcome | Type | Control | Intervention | HR / OR / RR | P-value |
|---|---|---|---|---|---|
| 90-day modified Rankin Scale score (ordinal shift) | Primary | No significant difference | No significant difference | 0.13 | |
| Baseline NIHSS score | Secondary | Median NIHSS 17 | Median NIHSS 14 | −2.39 difference | 0.007 |
| Early neurologic improvement (ΔNIHSS) | Secondary | Worse | ΔNIHSS +3.28 (95% CI 1.34–5.22) | 0.001 | |
| Any ICH | Adverse | 43.8% | 24.8% | OR 3.06 (95% CI 1.47–6.35) | 0.003 |
| Parenchymal Hematoma | Adverse | 11.5% | 7.8% |
Subgroup Analysis
RAS inhibition remained associated with better early neurological outcomes and lower ICH after multivariable adjustment. No significant interaction with age, IVT use, or BP group.
Criticisms
- Post hoc design limits causal inference
- Potential unmeasured confounding between antihypertensive groups
- Overlap in medication classes (some patients received both RAS and non-RAS drugs)
- Small sample size limits generalizability
Funding
French Ministry of Health (PHRC), Fondation de l'Avenir, Institut Servier
Based on: BP-TARGET AHT Substudy (Stroke, 2022)
Authors: Ben Assayag E, Lapergue B, Rouchaud A, ..., Soudant M
Citation: Stroke. 2022;53:3150–3159. doi:10.1161/STROKEAHA.122.039349
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