Higher versus lower blood pressure targets after cardiac arrest: Systematic review with individual patient data meta-analysis

Niemelä, Ville; Siddiqui, Farhan Ahmed; Ameloot, Koen; Reinikainen, Matti; Grand, Johannes; Hästbacka, Johanna; Hassager, Christian; Kjaergard, Jesper; Åneman, Anders; Tiainen, Marjaana; Nielsen, Niklas; Olsen, Markus Harboe; Jørgensen, Caroline Kamp; Petersen, Johanne Juul; Dankiewicz, Josef; Saxena, Manoj; Jakobsen, Janus Christian; Skrifvars, Markus B.

doi:10.1016/j.resuscitation.2023.109862

Cited by 17 publications

(5 citation statements)

References 34 publications

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“…Four randomized controlled trials have now investigated differential MAP targets, comparing the conventional target of 63 to 65 mm Hg with higher targets of 72 to 100 mm Hg. 4 Results were consistent in showing that a higher MAP target is unlikely to reduce mortality or improve neurological recovery after OHCA.…”

Section: See Article By Grand Et Almentioning

confidence: 64%

Blood Pressure Target in Out-of-Hospital Cardiac Arrest With Preexisting Heart Failure: (Don’t) Go With the Flow?

Schaubroeck,

Verbrugge

2024

Circ: Heart Failure

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Section: See Article By Grand Et Almentioning

confidence: 64%

Blood Pressure Target in Out-of-Hospital Cardiac Arrest With Preexisting Heart Failure: (Don’t) Go With the Flow?

Schaubroeck,

Verbrugge

2024

Circ: Heart Failure

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“…Comparisons were made using the Chisquare test or Mann-Whitney test when appropriate. Time to AKI was analysed using Cox proportional hazards regression, with the results reported as hazard ratios (HR) (95% confidence interval [22]). First, we entered age, no bystander CPR, non-shockable initial rhythm, hypertension, time to ROSC and the high-MAP target into five separate unadjusted models: (1) time to AKI of any severity (AKI KDIGO 1-3), (2) time to severe AKI (AKI KDIGO 2-3), (3) time to AKI of any severity (AKI KDIGO 1-3) when admission creatinine was used as baseline, (4) time to AKI of any severity (AKI KDIGO 1-3) when modified AKI KDIGO classification was based on creatinine and the average daily UO, and (5) time to AKI of any severity (AKI KDIGO 1-3) during the first 48 h after OHCA.…”

Section: Discussionmentioning

confidence: 99%

The effect of higher or lower mean arterial pressure on kidney function after cardiac arrest: a post hoc analysis of the COMACARE and NEUROPROTECT trials

Laurikkala,

Ameloot,

Reinikainen

et al. 2023

Ann. Intensive Care

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Background We aimed to study the incidence of acute kidney injury (AKI) in out-of-hospital cardiac arrest (OHCA) patients treated according to low-normal or high-normal mean arterial pressure (MAP) targets. Methods A post hoc analysis of the COMACARE (NCT02698917) and Neuroprotect (NCT02541591) trials that randomized patients to lower or higher targets for the first 36 h of intensive care. Kidney function was defined using the Kidney Disease Improving Global Outcome (KDIGO) classification. We used Cox regression analysis to identify factors associated with AKI after OHCA. Results A total of 227 patients were included: 115 in the high-normal MAP group and 112 in the low-normal MAP group. Eighty-six (38%) patients developed AKI during the first five days; 40 in the high-normal MAP group and 46 in the low-normal MAP group (p = 0.51). The median creatinine and daily urine output were 85 μmol/l and 1730 mL/day in the high-normal MAP group and 87 μmol/l and 1560 mL/day in the low-normal MAP group. In a Cox regression model, independent AKI predictors were no bystander cardiopulmonary resuscitation (p < 0.01), non-shockable rhythm (p < 0.01), chronic hypertension (p = 0.03), and time to the return of spontaneous circulation (p < 0.01), whereas MAP target was not an independent predictor (p = 0.29). Conclusion Any AKI occurred in four out of ten OHCA patients. We found no difference in the incidence of AKI between the patients treated with lower and those treated with higher MAP after CA. Higher age, non-shockable initial rhythm, and longer time to ROSC were associated with shorter time to AKI. Clinical trial registration: COMACARE (NCT02698917), NEUROPROTECT (NCT02541591).

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“…Nevertheless, the evidence remains inconclusive, with certain studies suggesting variances in markers of cardiac and neurological injury, findings that were not substantiated by the extensive BOX trial published in 2022 [27 ▪▪ ]. A recent meta-analysis failed to identify any compelling evidence supporting improved outcomes associated with a higher MAP target [28 ▪ ]. It is worth noting that the existing evidence can only exclude a relative effect exceeding 25%, translating to an absolute difference of 10−15% [28 ▪ ].…”

Section: Circulationmentioning

confidence: 99%

“…A recent meta-analysis failed to identify any compelling evidence supporting improved outcomes associated with a higher MAP target [28 ▪ ]. It is worth noting that the existing evidence can only exclude a relative effect exceeding 25%, translating to an absolute difference of 10−15% [28 ▪ ]. Future research endeavors should center on investigating whether targeting a higher MAP may yield a more modest effect and whether specific patient subpopulations might derive distinct benefits from alternative MAP targets.…”

Section: Circulationmentioning

confidence: 99%

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Postresuscitation management

Behringer,

Skrifvars,

Taccone

2023

Current Opinion in Critical Care

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Purpose of review To describe the most recent scientific evidence on ventilation/oxygenation, circulation, temperature control, general intensive care, and prognostication after successful resuscitation from adult cardiac arrest. Recent findings Targeting a lower oxygen target (90–94%) is associated with adverse outcome. Targeting mild hypercapnia is not associated with improved functional outcomes or survival. There is no compelling evidence supporting improved outcomes associated with a higher mean arterial pressure target compared to a target of >65 mmHg. Noradrenalin seems to be the preferred vasopressor. A low cardiac index is common over the first 24 h but aggressive fluid loading and the use of inotropes are not associated with improved outcome. Several meta-analyses of randomized clinical trials show conflicting results whether hypothermia in the 32–34°C range as compared to normothermia or no temperature control improves functional outcome. The role of sedation is currently under evaluation. Observational studies suggest that the use of neuromuscular blockade may be associated with improved survival and functional outcome. Prophylactic antibiotic does not impact on outcome. No single predictor is entirely accurate to determine neurological prognosis. The presence of at least two predictors of severe neurological injury indicates that an unfavorable neurological outcome is very likely. Summary Postresuscitation care aims for normoxemia, normocapnia, and normotension. The optimal target core temperature remains a matter of debate, whether to implement temperature management within the 32–34°C range or focus on fever prevention, as recommended in the latest European Resuscitation Council/European Society of Intensive Care Medicine guidelines Prognostication of neurological outcome demands a multimodal approach.

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Higher versus lower blood pressure targets after cardiac arrest: Systematic review with individual patient data meta-analysis

Cited by 17 publications

References 34 publications

Blood Pressure Target in Out-of-Hospital Cardiac Arrest With Preexisting Heart Failure: (Don’t) Go With the Flow?

Blood Pressure Target in Out-of-Hospital Cardiac Arrest With Preexisting Heart Failure: (Don’t) Go With the Flow?

The effect of higher or lower mean arterial pressure on kidney function after cardiac arrest: a post hoc analysis of the COMACARE and NEUROPROTECT trials

Postresuscitation management

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