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Mortality effect of higher versus lower blood pressure targets in vasodilatory shock: an updated systematic review
Henrique Mendes1, Jesse King2, Nikhil Kumar3
1St George Hospital, Gray Street, Kogarah, Sydney, 2217, NSW, Australia. henrique.gomesmendes@health.nsw.gov.au.
Objective:
To determine the impact of higher versus lower mean arterial pressure (MAP) targets on mortality and other outcomes in patients with vasodilatory shock.
Design:
A systematic review and meta-analysis of randomised controlled trials (RCTs) following PRISMA guidelines with the protocol preregistered with PROSPERO (CRD420251087844).
Data Sources:
PubMed, Embase, CENTRAL, and Scopus from their inception until July 2025.
Methods:
This review included RCTs that compared a higher MAP target arm, typically 80±5 mmHg or the physiologically higher target arm within the trial, to a lower target arm (generally 65±5 mmHg) in adult patients with vasodilatory shock. The primary outcome was all-cause mortality. The analysis utilised random-effects models, subgroup analyses, and Bayesian methods.
Results:
Four RCTs with a total of 3,873 patients were included. A higher MAP target was associated with a 10% increase in 28-day mortality (RR 1.10, 95% CI 1.01-1.19; P=0.03). A similar trend toward increased 90-day mortality was observed, with a risk ratio of 1.10 (95% CI 1.00-1.22; P=0.05). Subgroup analyses revealed no benefit from higher targets for any patient group, including those with advanced age or chronic hypertension. A higher MAP target was also linked to fewer RRT-free days (mean difference -1.64, 95% CI -3.05 to -0.23; P = 0.02) and a greater risk of arrhythmia (RR 1.32, 95% CI 1.01-1.72; P=0.04). The Bayesian analysis corroborated these findings, revealing a high posterior probability of harm (97.8% for 28-day mortality and 98.7% for 90-day mortality).
Conclusions:
In patients with vasodilatory shock, universal high MAP targets are associated with increased mortality compared with lower targets, with moderate certainty. These results should encourage the adoption of lower MAP targets and highlight the importance of avoiding the potential harm associated with excessive vasopressor use. Future research should focus on individualised blood pressure rather than fixed targets.
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