Key result
Lower MAP targets for vasopressors show no 90-day mortality benefit over higher targets in vasodilatory shock.
Why the study?
It was uncertain whether targeting a lower mean arterial blood pressure compared with a higher target reduces 90-day all-cause mortality in critically ill adults with vasodilatory shock.
Does a lower mean arterial blood pressure target reduce 90-day all-cause mortality in critically ill adult patients with vasodilatory shock?
Meta-Analysis (n=3,352)
Randomized
Yes
Does a lower mean arterial blood pressure target reduce 90-day all-cause mortality in critically ill adult patients with vasodilatory shock?
Relative Risk: 0.93 (95% CI 0.76–1.07)
Targeting a lower mean arterial blood pressure for vasopressor therapy in critically ill patients with vasodilatory shock possibly reduces 90-day all-cause mortality, though the certainty of evidence is low.
Lower MAP targets show uncertain mortality benefit in vasodilatory shock; leaves open optimal vasopressor goals for trials.
BACKGROUND: We sought to estimate whether a lower mean arterial blood pressure target, compared with a higher mean arterial blood pressure target, reduced 90-day all-cause mortality among critically ill adult patients with vasodilatory shock. METHODS: We conducted an individual patient data meta-analysis of randomized controlled trials that evaluated the effect of distinct thresholds of mean arterial blood pressure to guide vasopressor support among critically ill adults identified in a systematic literature search. The main exposure was a lower mean arterial pressure target compared with a higher mean arterial pressure target (including usual care). The primary outcome was 90-day all-cause mortality. We used a Bayesian random effects log-binomial model to estimate risk ratios with 95% credible intervals (CrIs). RESULTS: Between 2010 and 2019, 3352 patients were randomly assigned in three trials (SEPSISPAM, OVATION pilot trial, and 65-Trial) across 103 hospitals from the United Kingdom, France, and Canada. When compared with a higher mean arterial blood pressure target or usual care, the risk ratio for 90-day all-cause mortality associated with a lower blood pressure target was 0.93 (95% CrI, 0.76 to 1.07; low certainty, posterior probability of benefit 87%). Results were consistent across multiple secondary and sensitivity analyses, including adjustment for prognostically important baseline covariates and alternative modeling techniques. Multiple approaches to evaluate the heterogeneity of treatment effect did not identify any subgroups that may potentially benefit from higher mean arterial blood pressure targets. CONCLUSIONS: Targeting a lower mean arterial blood pressure for vasopressor therapy in critically ill patients with vasodilatory shock possibly reduced 90-day all-cause mortality. However, the certainty of evidence is low, and this analysis does not exclude the possibility that lower targets may cause harm overall.
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Angriman et al. (2024) conducted a meta-analysis in Vasodilatory shock (n=3,352). Lower mean arterial blood pressure target vs. Higher mean arterial blood pressure target or usual care was evaluated on 90-day all-cause mortality (RR 0.93, 95% CI 0.76 to 1.07). Targeting a lower mean arterial blood pressure for vasopressor therapy in critically ill adults with vasodilatory shock yielded a risk ratio of 0.93 (95% CrI 0.76-1.07) for 90-day mortality.
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