Pooled analysis of higher versus lower blood pressure targets for vasopressor therapy septic and vasodilatory shock

• Published in: Intensive care medicine Vol. 44; no. 1; pp. 12 - 21
• Main Authors: Lamontagne, François, Day, Andrew G., Meade, Maureen O., Cook, Deborah J., Guyatt, Gordon H., Hylands, Mathieu, Radermacher, Peter, Chrétien, Jean-Marie, Beaudoin, Nicolas, Hébert, Paul, D’Aragon, Frédérick, Meziani, Ferhat, Asfar, Pierre
• Format: Journal Article
• Language: English
• Published: Berlin/Heidelberg Springer Berlin Heidelberg 01.01.2018; Springer; Springer Nature B.V; Springer Verlag
• Subjects: Adult; Analysis; Anesthesiology; Arteriosclerosis; Atherosclerosis; Blood Pressure; Blood vessels; Canada; Care and treatment; Clinical trials; Congestive heart failure; Critical Care Medicine; Data processing; Dilatation; Emergency Medicine; Health aspects; Heart; Humans; Hypertension; Hypotension; Intensive; Intensive care; Life Sciences; Male; Medicine; Medicine & Public Health; Meta-analysis; Mortality; Pain Medicine; Patients; Pediatrics; Pneumology/Respiratory System; Quality of Life; Quebec; Randomization; Randomized Controlled Trials as Topic; Shock; Shock, Septic - drug therapy; Systematic Review; Therapy; Vasoconstrictor Agents - therapeutic use; Vasodilators; Canada; Quebec; Critical care; Individual patient data meta-analysis; Vasopressors; Mean arterial blood pressure; Hypotension; Blood Pressure; Shock; Vasoconstrictor Agents; Humans; Septic; Adult; Male; Quality of life; Randomized Controlled Trials as Topic
• ISSN: 0342-4642; 1432-1238; 1432-1238
• DOI: 10.1007/s00134-017-5016-5

Purpose Guidelines for shock recommend mean arterial pressure (MAP) targets for vasopressor therapy of at least 65 mmHg and, until recently, suggested that patients with underlying chronic hypertension and atherosclerosis may benefit from higher targets. We conducted an individual patient-data meta-analysis of recent trials to determine if patient variables modify the effect of different MAP targets. Methods We searched the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials for randomized controlled trials of higher versus lower blood pressure targets for vasopressor therapy in adult patients in shock (until November 2017). After obtaining individual patient data from both eligible trials, we used a modified version of the Cochrane Collaboration’s instrument to assess the risk of bias of included trials. The primary outcome was 28-day mortality. Results Included trials enrolled 894 patients. Controlling for trial and site, the OR for 28-day mortality for the higher versus lower MAP targets was 1.15 (95% CI 0.87–1.52). Treatment effect varied by duration of vasopressors before randomization (interaction p  = 0.017), but not by chronic hypertension, congestive heart failure or age. Risk of death increased in higher MAP groups among patients on vasopressors > 6 h before randomization (OR 3.00, 95% CI 1.33–6.74). Conclusions Targeting higher blood pressure targets may increase mortality in patients who have been treated with vasopressors for more than 6 h. Lower blood pressure targets were not associated with patient-important adverse events in any subgroup, including chronically hypertensive patients.