BEST-II Trial: Blood Pressure Targets After Successful Endovascular Therapy
After successful EVT, does targeting a lower systolic blood pressure (SBP less than 140 or less than 160 mm Hg) improve utility-weighted functional outcomes at 90 days compared with permissive control (SBP at or below 180 mm Hg)?
Mistry et al. (JAMA 2023) · doi:10.1001/jama.2023.14330 · 120 patients
Population
Included
- Age 18 or older
- Anterior circulation LVO stroke
- Successful EVT (mTICI 2c or better)
- BP target initiated within 60 minutes of procedure end
- Treatment maintained for 24 hours
- Adult patients aged 18 years or older
- Ischaemic stroke who had undergone successful endovascular therapy, defined as modified Thrombolysis in Cerebral Infarction (mTICI) 2b (50% to 89% reperfusion), 2c (90% to 99% reperfusion), or 3 (complete reperfusion)
- Occlusion in an anterior circulation large vessel, specifically the internal carotid artery and the M1 or M2 segments of the middle cerebral artery
- Able to be randomised within 45 minutes of final recanalisation
Excluded
- Unsuccessful EVT (mTICI below 2c)
- Severe heart failure (EF below 30%)
- LVAD or extracorporeal membrane oxygenation
- Pre-stroke mRS greater than 2
- Unable to maintain assigned BP target
- Heart failure with ejection fraction less than 30%
- Left ventricular assist device
- Extracorporeal membrane oxygenation
- Pregnant individuals
- Patients enrolled in other clinical trials
Source: Mistry et al., JAMA 2023;330(9):821–831 (BEST-II)· Retrieved 2026-06-09
Futility design: low predicted success for lower BP targets
BEST-II was a phase 2 futility trial. Neither lower target formally crossed the futility boundary (P=0.93), but predicted success in a future superiority trial was only 14-25% for lower targets. The highest-target arm (SBP <=180 mm Hg) produced the best utility-weighted mRS (0.58 vs 0.51). OPTIMAL-BP subsequently confirmed functional harm from SBP <140 mm Hg.
Primary Outcome — Utility-Weighted mRS at 90 days (x100)
120 patients; 3-arm futility trial: SBP <140, <160, or <=180 mm Hg after successful EVT
Negligible absolute difference
Utility-Weighted mRS at 90 days (x100)
Study Arms
- Agent
- Intravenous nicardipine (first-line); intravenous labetalol and hydralazine recommended as second-line and third-line agents
- Dose
- Target systolic blood pressure less than 140 mm Hg
- Route
- Intravenous
- Frequency
- Titrated to target; agent reduced or stopped if SBP fell below the next lower target
- Duration
- Initiated within 60 minutes of recanalisation and maintained for 24 hours
- Co-interventions
- Standard post-EVT stroke-unit care. BP monitored noninvasively (recumbent cuff) every 5 min for the first 15 min after nicardipine initiation or dose adjustment, every 15 min for the first hour, then at least every 30 min for 24 hours; arterial-line monitoring allowed but not required.
n=40 randomised (1:1:1, block sizes 3, 6, 9). Lowest of three futility-design targets. Mistry JAMA 2023 p.822.
- Agent
- Intravenous nicardipine (first-line); labetalol and hydralazine second-line and third-line
- Dose
- Target systolic blood pressure less than 160 mm Hg
- Route
- Intravenous
- Frequency
- Titrated to target; agent reduced or stopped if SBP fell below the next lower target
- Duration
- Initiated within 60 minutes of recanalisation and maintained for 24 hours
- Co-interventions
- Standard post-EVT stroke-unit care with the same noninvasive BP-monitoring schedule.
n=40 randomised. Middle of three futility-design targets. Mistry JAMA 2023 p.822.
- Agent
- Intravenous nicardipine (first-line); labetalol and hydralazine second-line and third-line
- Dose
- Target systolic blood pressure 180 mm Hg or less (current guideline-recommended target)
- Route
- Intravenous
- Frequency
- Treated to keep SBP at or below 180 mm Hg
- Duration
- Initiated within 60 minutes of recanalisation and maintained for 24 hours
- Co-interventions
- Standard post-EVT stroke-unit care with the same noninvasive BP-monitoring schedule.
n=40 randomised. Higher guideline-recommended comparator target; had the best mean utility-weighted mRS in this phase 2 study. Mistry JAMA 2023 p.821-822.
Trial Design
Type
- Phase 2 randomized open-label blinded-endpoint futility trial
- Three post-EVT systolic blood pressure targets: <140, <160, and <=180 mm Hg
- Successful endovascular therapy required before randomization
- Blood pressure strategy initiated within 60 minutes and maintained for 24 hours
Timeline
Three US comprehensive stroke centers, 2020-2022
N
120
Enrollment
120 patients at three US comprehensive stroke centers. Phase 2 open-label randomized futility trial with three arms. BP targeting initiated within 60 minutes of successful EVT and maintained for 24 hours. Published JAMA 2023.
ClinicalTrials.gov
NCT04116112Bedside Pearl
BEST-II and OPTIMAL-BP together make a consistent case: permissive BP management (SBP up to 180 mm Hg) is safer than aggressive lowering after successful EVT. BEST-II showed low predicted benefit from lower targets; OPTIMAL-BP confirmed functional harm. Do not force SBP below 140 mm Hg in the first 24 hours after successful reperfusion.