A randomised double-blind pilot trial comparing a mean arterial pressure target of 65 mm Hg versus 72 mm Hg after out-of-hospital cardiac arrest

Abstract

Background: After resuscitation from out-of-hospital cardiac arrest, mean arterial pressure below 65 mm Hg is avoided with vasopressors. A higher blood-pressure target could potentially improve outcome. The aim of this pilot trial was to investigate the effect of a higher mean arterial pressure target on biomarkers of organ injury. Methods: This was a single-centre, double-blind trial of 50 consecutive, comatose out-of-hospital cardiac arrest patients randomly assigned in a 1:1 ratio to a mean arterial pressure target of 65 mm Hg (MAP65) or 72 mm Hg (MAP72). Modified blood pressure modules with a –10% offset were used, enabling a double-blind study design. End-points were biomarkers of organ injury including markers of endothelial integrity (soluble trombomodulin) brain damage (neuron-specific enolase) and renal function (estimated glomerular filtration rate). Results: Mean arterial pressure was significantly higher in MAP72 with a mean difference of 5 mm Hg ( pgroup=0.03). After 48 h, soluble trombomodulin (median (interquartile range)) was 8.2 (6.7–12.9) ng/ml and 8.3 (6.0–10.8) ng/ml ( p=0.29), neuron-specific enolase was 20 (13–31 μg/l) and 18 (13–44 μg/l) p=0.79) and estimated glomerular filtration rate (mean (±standard deviation)) was 61±19 ml/min/1.73m2 and 48±22 ml/min/1.73 m2 ( p=0.08) for the MAP72 and MAP65 groups, respectively. Renal replacement therapy was needed in eight patients (31%) in MAP65 and three patients (13%) in MAP72 ( p=0.14). Conclusions: Double-blind allocation to different mean arterial pressure targets is feasible in comatose out-of-hospital cardiac arrest patients. A mean arterial pressure target of 72 mm Hg compared to 65 mm Hg did not result in improved biomarkers of organ injury. We observed a trend towards preserved renal function in the MAP72 group.

Early Higher Achieved Mean Arterial Pressure Is Not Associated with Clinical Outcomes after Cardiac Arrest: A systematic Review and Meta-analysis

“…Among these full studies, ve were excluded for unavailable data, four were excluded because they were studies, and three were excluded due to duplication of data. Finally, nine studies [4][5][6][7][8][9][10][11][12] were included in this meta-analysis.…”

“…The characteristics of the included studies [4][5][6][7][8][9][10][11][12] are outlined in Table 1. The mean age ranged from 58 years to 63 years, the proportion of male subject varied from 58-88%, and the duration of MAP target was between 2 and 96 h. Four studies [9][10][11][12] were conducted in North America, three [4,6,8] in Europe, and two in Asia [5]. The risk of bias assessment for each included study and the summative assessment by domain are shown in Supplementary Tables 1 and 2.…”

“…Nine studies [4][5][6][7][8][9][10][11][12] with 1337 patients reported the relation between MAP target and neurologic outcome after discharge. The pooled result with the random-effect model showed that high MAP was associated with similar neurologic outcome to low MAP (OR 1.30, 95% CI 0.65-2.58, p = 0.46; I 2 = 86%, p < 0.001; Fig.…”

“…Three studies [4][5][6] with 251 patients reported the relation between MAP target and length of ICU stay. The pooled result with the xed-effect model indicated that high MAP was associated with similar length of ICU stay to low MAP (OR -0.06, 95% CI -0.31-0.19, p = 0.46; I 2 = 0%, p = 0.58; Fig.…”

“…Several studies [4][5][6][7][8][9][10][11][12] assessed early high versus low MAP target for neurologic outcome after CA; However, whether the use of vasoactive drugs to achieve higher MAP will increase survival remains unknown. In the present work, we performed an updated meta-analysis to evaluate early high achieved MAP target for clinical outcomes after CA.…”