What is the clinical evidence from this study?

Study design: Systematic Review. Population: Distributive shock. Intervention: Angiotensin II vs. Placebo or standards of care. Primary outcome: Change in background vasopressor requirements (norepinephrine equivalent dose) at 3 hours (p=<0.001).

What does this research mean for the field?

Angiotensin II administration in distributive shock is a safe and effective vasopressor that significantly decreases background vasopressor requirements and consistently improves mean arterial pressure. Novelty: ClaimNovelty.SYNTHESIS. Consensus alignment: ConsensusAlignment.NEUTRAL.

What question did this study set out to answer?

This overview aims to summarize systematic reviews on the benefits of Angiotensin II in managing distributive shock and to identify gaps in current knowledge.

April 8, 2026Open Access

An overview of reviews of Angiotensin II in distributive shock

Q: What are the key findings of this study?

Angiotensin II administration in distributive shock significantly decreased background vasopressor requirements by 200 ng/kg/min at 3 hours compared to a 40 ng/kg/min increase with placebo.

Q: What does this research mean for the field?

Angiotensin II administration in distributive shock is a safe and effective vasopressor that significantly decreases background vasopressor requirements and consistently improves mean arterial pressure. Novelty: ClaimNovelty.SYNTHESIS. Consensus alignment: ConsensusAlignment.NEUTRAL.

Q: What question did this study set out to answer?

This overview aims to summarize systematic reviews on the benefits of Angiotensin II in managing distributive shock and to identify gaps in current knowledge.

Key Result

Angiotensin II administration in distributive shock significantly decreased background vasopressor requirements by 200 ng/kg/min at 3 hours compared to a 40 ng/kg/min increase with placebo.

Key Points

This overview aims to summarize systematic reviews on the benefits of Angiotensin II in managing distributive shock and to identify gaps in current knowledge.
Conducted a systematic literature search for reviews from 2020 using multiple databases.
Utilized the AMSTAR 2 checklist to assess review quality.
Evaluated the certainty of evidence with the GRADE tool.
Summarized qualitative and quantitative data from included reviews.
Identified 6 systematic reviews, with generally low methodological quality.
Angiotensin II administration reduced background vasopressor needs.
No statistically significant serious adverse reactions were found.
Mortality benefits were observed in specific patient sub-groups.
Angiotensin II showed consistent improvement in mean arterial pressure by over 10 mmHg.

Study Design

Type

Systematic Review

Structured PICO

Does Angiotensin II improve mean arterial pressure and reduce background vasopressor requirements in patients with distributive shock?

Population

Patients with distributive shock or vasoplegic shock (defined as difficulty maintaining mean arterial pressure > 65 mmHg despite standards of care with preserved cardiac index of at least 2.2 L/min/m2). The most common etiologies were septic shock and post-cardiopulmonary bypass vasoplegia.

Intervention

Angiotensin II (initial dose 5 to 20 ng/kg/min, maximum dose 40 to 200 ng/kg/min) administered once standards-of-care thresholds have been met.

Comparator

Placebo once standards-of-care thresholds had been met or standards-of-care alone (intravenous volume resuscitation of 25 ml/kg and vasopressor requirements).

Outcome

Changes in mean arterial pressure (MAP) following Angiotensin II administration, effects on background vasopressor requirements or catecholamine dose reduction, mortality, occurrence of serious adverse events, and reported Angiotensin II dosing practices.

Angiotensin II is a safe and effective adjunct vasopressor that significantly improves mean arterial pressure and reduces background catecholamine requirements in patients with distributive shock.

Main Result

Absolute Event Rate: -200% vs 40%

p-value: p=<0.001

Limitations

Methodological quality of included reviews was mostly low to critically low
Considerable overlap of primary studies amongst the included reviews
Non-standardized reporting of quantitative summary measures prevented a meta-analysis

Abstract

High-dose catecholamine use in distributive shock is associated with high mortality. Angiotensin II (ATII) has demonstrated benefits in distributive shock patients, yet limited and inconsistent clinical data precludes its publication in treatment guidelines. This overview of reviews aims to critically assess and summarize systematic reviews on ATII benefits in distributive shock, identify knowledge gaps, and provide recommendations for future research. A systematic literature search for systematic reviews on the topic from 2020 was conducted, including PubMed, Embase, CINAHL, Epistemonikos, Scopus, PROSPERO, and Cochrane, and gray literature. Reviews were assessed by the Assessment of Multiple Systematic Reviews 2 (AMSTAR 2) checklist. Certainty of evidence was calculated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool. Both qualitative and quantitative data were summarized. The literature search yielded 239 results, resulting in 6 systematic reviews being included. The methodological quality was mostly low. ATII administration was associated with a decrease in background vasopressor requirements. Occurrence of serious adverse reactions were not found to be statistically significant. Mortality benefits was found in certain patient sub-groups but cannot be generalized. A consistent finding was that ATII improved MAP > 10 mmHg from baseline. ATII appears to be a safe and effective vasopressor in distributive shock management. The physiological and logistical benefits should be considered early in distributive shock management. This overview of reviews has identified certain gaps in the definition of catecholamine-resistant shock, ATII initiation thresholds, biomarker guided treatment, and occurrence of hemodynamic relapse which may guide future aspiring clinical trials.

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