Pooled analysis of higher versus lower blood pressure targets for vasopressor therapy septic and vasodilatory shock |
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Authors: | François Lamontagne Andrew G. Day Maureen O. Meade Deborah J. Cook Gordon H. Guyatt Mathieu Hylands Peter Radermacher Jean-Marie Chrétien Nicolas Beaudoin Paul Hébert Frédérick D’Aragon Ferhat Meziani Pierre Asfar |
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Affiliation: | 1.Department of Medicine,Université de Sherbrooke,Sherbrooke,Canada;2.Centre de recherche du CHU de Sherbrooke,Sherbrooke,Canada;3.Kingston General Hospital,Kingston,Canada;4.Interdepartmental Division of Critical Care,Hamilton Health Sciences,Hamilton,Canada;5.Departments of Medicine and Clinical Epidemiology and Biostatistics,McMaster University,Hamilton,Canada;6.Department of Surgery,Université de Sherbrooke,Sherbrooke,Canada;7.Institute of Anesthesiological Pathophysiology and Process Engineering,Ulm University Hospital,Ulm,Germany;8.Department of Clinical Research and Innovation,University Hospital of Anger,Angers,France;9.Department of Anesthesiology,Université de Sherbrooke,Sherbrooke,Canada;10.Department of Medicine,University of Montreal,Montreal,Canada;11.Service de Réanimation Médicale, Nouvel H?pital Civil,Centre Hospitalo-Universitaire,Strasbourg,France;12.Department of Medical Intensive Care,University Hospital of Angers,Angers,France |
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Abstract: | PurposeGuidelines 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.MethodsWe 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.ResultsIncluded 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).ConclusionsTargeting 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. |
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