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

Niemelä, Ville ; Siddiqui, Faiza LU ; Ameloot, Koen ; Reinikainen, Matti ; Grand, Johannes ; Hästbacka, Johanna ; Hassager, Christian ; Kjaergaard, Jesper ; Åneman, Anders and Tiainen, Marjaana , et al. (2023) In Resuscitation 189.
Abstract

Purpose: Guidelines recommend targeting mean arterial pressure (MAP) > 65 mmHg in patients after cardiac arrest (CA). Recent trials have studied the effects of targeting a higher MAP as compared to a lower MAP after CA. We performed a systematic review and individual patient data meta-analysis to investigate the effects of higher versus lower MAP targets on patient outcome. Method: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, LILACS, BIOSIS, CINAHL, Scopus, the Web of Science Core Collection, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry, Google Scholar and the Turning Research into Practice database to identify trials randomizing patients to higher (≥71... (More)

Purpose: Guidelines recommend targeting mean arterial pressure (MAP) > 65 mmHg in patients after cardiac arrest (CA). Recent trials have studied the effects of targeting a higher MAP as compared to a lower MAP after CA. We performed a systematic review and individual patient data meta-analysis to investigate the effects of higher versus lower MAP targets on patient outcome. Method: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, LILACS, BIOSIS, CINAHL, Scopus, the Web of Science Core Collection, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry, Google Scholar and the Turning Research into Practice database to identify trials randomizing patients to higher (≥71 mmHg) or lower (≤70 mmHg) MAP targets after CA and resuscitation. We used the Cochrane Risk of Bias tool, version 2 (RoB 2) to assess for risk of bias. The primary outcomes were 180-day all-cause mortality and poor neurologic recovery defined by a modified Rankin score of 4–6 or a cerebral performance category score of 3–5. Results: Four eligible clinical trials were identified, randomizing a total of 1,087 patients. All the included trials were assessed as having a low risk for bias. The risk ratio (RR) with 95% confidence interval for 180-day all-cause mortality for a higher versus a lower MAP target was 1.08 (0.92–1.26) and for poor neurologic recovery 1.01 (0.86–1.19). Trial sequential analysis showed that a 25% or higher treatment effect, i.e., RR < 0.75, can be excluded. No difference in serious adverse events was found between the higher and lower MAP groups. Conclusions: Targeting a higher MAP compared to a lower MAP is unlikely to reduce mortality or improve neurologic recovery after CA. Only a large treatment effect above 25% (RR < 0.75) could be excluded, and future studies are needed to investigate if relevant but lower treatment effect exists. Targeting a higher MAP was not associated with any increase in adverse effects.

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organization
publishing date
type
Contribution to journal
publication status
published
subject
keywords
Blood pressure, Cardiac arrest, Meta-analysis, Systematic review, Target
in
Resuscitation
volume
189
article number
109862
publisher
Elsevier
external identifiers
  • pmid:37295549
  • scopus:85162110362
ISSN
0300-9572
DOI
10.1016/j.resuscitation.2023.109862
language
English
LU publication?
yes
id
a7705441-7b34-48ec-9184-3363dff985dd
date added to LUP
2023-09-11 13:51:20
date last changed
2024-04-20 03:03:01
@article{a7705441-7b34-48ec-9184-3363dff985dd,
  abstract     = {{<p>Purpose: Guidelines recommend targeting mean arterial pressure (MAP) &gt; 65 mmHg in patients after cardiac arrest (CA). Recent trials have studied the effects of targeting a higher MAP as compared to a lower MAP after CA. We performed a systematic review and individual patient data meta-analysis to investigate the effects of higher versus lower MAP targets on patient outcome. Method: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, LILACS, BIOSIS, CINAHL, Scopus, the Web of Science Core Collection, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry, Google Scholar and the Turning Research into Practice database to identify trials randomizing patients to higher (≥71 mmHg) or lower (≤70 mmHg) MAP targets after CA and resuscitation. We used the Cochrane Risk of Bias tool, version 2 (RoB 2) to assess for risk of bias. The primary outcomes were 180-day all-cause mortality and poor neurologic recovery defined by a modified Rankin score of 4–6 or a cerebral performance category score of 3–5. Results: Four eligible clinical trials were identified, randomizing a total of 1,087 patients. All the included trials were assessed as having a low risk for bias. The risk ratio (RR) with 95% confidence interval for 180-day all-cause mortality for a higher versus a lower MAP target was 1.08 (0.92–1.26) and for poor neurologic recovery 1.01 (0.86–1.19). Trial sequential analysis showed that a 25% or higher treatment effect, i.e., RR &lt; 0.75, can be excluded. No difference in serious adverse events was found between the higher and lower MAP groups. Conclusions: Targeting a higher MAP compared to a lower MAP is unlikely to reduce mortality or improve neurologic recovery after CA. Only a large treatment effect above 25% (RR &lt; 0.75) could be excluded, and future studies are needed to investigate if relevant but lower treatment effect exists. Targeting a higher MAP was not associated with any increase in adverse effects.</p>}},
  author       = {{Niemelä, Ville and Siddiqui, Faiza and Ameloot, Koen and Reinikainen, Matti and Grand, Johannes and Hästbacka, Johanna and Hassager, Christian and Kjaergaard, Jesper and Åneman, Anders and Tiainen, Marjaana and Nielsen, Niklas and Harboe Olsen, Markus and Jorgensen, Caroline Kamp and Juul Petersen, Johanne and Dankiewicz, Josef and Saxena, Manoj and Jakobsen, Janus C. and Skrifvars, Markus B.}},
  issn         = {{0300-9572}},
  keywords     = {{Blood pressure; Cardiac arrest; Meta-analysis; Systematic review; Target}},
  language     = {{eng}},
  publisher    = {{Elsevier}},
  series       = {{Resuscitation}},
  title        = {{Higher versus lower blood pressure targets after cardiac arrest : Systematic review with individual patient data meta-analysis}},
  url          = {{http://dx.doi.org/10.1016/j.resuscitation.2023.109862}},
  doi          = {{10.1016/j.resuscitation.2023.109862}},
  volume       = {{189}},
  year         = {{2023}},
}