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Higher versus lower blood pressure targets after cardiac arrest: Systematic review with individual patient data
Ville Niemelä1, Faiza Siddiqui2, Koen Ameloot3
1Department of Anaesthesia and Intensive Care, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
Insights
Targeting a higher mean arterial pressure (MAP) after cardiac arrest (CA) does not appear to improve survival or neurological recovery. Further research is needed to determine if a smaller benefit exists, as higher MAP targets did not increase adverse events.
Area of Science:
- Critical Care Medicine
- Cardiovascular Research
- Neurology
Background:
- Current guidelines recommend a mean arterial pressure (MAP) target of >65 mmHg following cardiac arrest (CA).
- Recent clinical trials have explored the impact of higher versus lower MAP targets on patient outcomes post-CA.
- This study systematically reviews and meta-analyzes individual patient data to evaluate these differing MAP targets.
Approach:
- A comprehensive search of multiple databases identified four eligible randomized controlled trials involving 1,087 patients.
- Risk of bias was assessed using the Cochrane Risk of Bias tool (version 2).
- Primary outcomes included 180-day all-cause mortality and poor neurological recovery.
Key Points:
- Higher MAP targets (≥71 mmHg) versus lower targets (≤70 mmHg) showed no significant difference in 180-day mortality (RR 1.08, 95% CI 0.92-1.26).
- Neurological recovery outcomes were also similar between groups (RR 1.01, 95% CI 0.86-1.19).
- Trial sequential analysis excluded a treatment effect of 25% or greater (RR < 0.75).
Conclusions:
- Targeting a higher MAP post-CA is unlikely to reduce mortality or improve neurological outcomes.
- While large treatment effects are unlikely, further studies are warranted to explore potential smaller benefits.
- Higher MAP targets were not associated with an increased risk of serious adverse events.
Purpose:
Guidelines recommend targeting mean arterial pressure (MAP) > 65 mmHg in patients after cardiac arrest (CA). Recent trials have studied the effects of targeting a higher MAP as compared to a lower MAP after CA. We performed a systematic review and individual patient data meta-analysis to investigate the effects of higher versus lower MAP targets on patient outcome.
Method:
We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, LILACS, BIOSIS, CINAHL, Scopus, the Web of Science Core Collection, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry, Google Scholar and the Turning Research into Practice database to identify trials randomizing patients to higher (≥71 mmHg) or lower (≤70 mmHg) MAP targets after CA and resuscitation. We used the Cochrane Risk of Bias tool, version 2 (RoB 2) to assess for risk of bias. The primary outcomes were 180-day all-cause mortality and poor neurologic recovery defined by a modified Rankin score of 4-6 or a cerebral performance category score of 3-5.
Results:
Four eligible clinical trials were identified, randomizing a total of 1,087 patients. All the included trials were assessed as having a low risk for bias. The risk ratio (RR) with 95% confidence interval for 180-day all-cause mortality for a higher versus a lower MAP target was 1.08 (0.92-1.26) and for poor neurologic recovery 1.01 (0.86-1.19). Trial sequential analysis showed that a 25% or higher treatment effect, i.e., RR < 0.75, can be excluded. No difference in serious adverse events was found between the higher and lower MAP groups.
Conclusions:
Targeting a higher MAP compared to a lower MAP is unlikely to reduce mortality or improve neurologic recovery after CA. Only a large treatment effect above 25% (RR < 0.75) could be excluded, and future studies are needed to investigate if relevant but lower treatment effect exists. Targeting a higher MAP was not associated with any increase in adverse effects.
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Monitoring Both Arms:
Monitoring BP in both arms during the initial assessment is advisable, as the systolic value may differ by five to ten mm Hg between arms. For subsequent BP assessments, use the arm with the higher reading.