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

Ville Niemelä; Faiza Siddiqui; Koen Ameloot; Matti Reinikainen; Johannes Grand; Johanna Hästbacka; Christian Hassager; Jesper Kjaergaard; Anders Åneman; Marjaana Tiainen; Niklas Nielsen; Markus Harboe Olsen; Caroline Kamp Jorgensen; Johanne Juul Petersen; Josef Dankiewicz; Manoj Saxena; Janus C Jakobsen; Markus B Skrifvars

doi:10.1016/j.resuscitation.2023.109862

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

Resuscitation. 2023 Aug:189:109862. doi: 10.1016/j.resuscitation.2023.109862. Epub 2023 Jun 8.

Authors

Ville Niemelä¹, Faiza Siddiqui², Koen Ameloot³, Matti Reinikainen⁴, Johannes Grand⁵, Johanna Hästbacka⁶, Christian Hassager⁵, Jesper Kjaergaard⁵, Anders Åneman⁷, Marjaana Tiainen⁸, Niklas Nielsen⁹, Markus Harboe Olsen¹⁰, Caroline Kamp Jorgensen¹¹, Johanne Juul Petersen², Josef Dankiewicz¹², Manoj Saxena¹³, Janus C Jakobsen¹¹, Markus B Skrifvars¹⁴

Affiliations

¹ Department of Anaesthesia and Intensive Care, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
² Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
³ Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Department of Cardiology, University Hospitals Leuven, Leuven, Belgium; Faculty of Medicine and Life Sciences, University Hasselt, Diepenbeek, Belgium.
⁴ Department of Anaesthesiology and Intensive Care, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland.
⁵ Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
⁶ Department of Anaesthesiology and Intensive Care, Tampere University Hospital and Tampere University, Tampere, Finland.
⁷ Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, South Western Clinical School, University of New South Wales, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.
⁸ Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
⁹ Lund University and Department of Clinical Sciences Lund, Anaesthesia and Intensive Care, Helsingborg Hospital, Lund, Sweden; Skåne University Hospital, Clinical Studies Sweden - Forum South, Lund, Sweden; Anaesthesia and Intensive Care, Helsingborg Hospital, Lund, Sweden.
¹⁰ Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Clinical Sciences Lund, Cardiology, Skåne University Hospital, Lund University, Lund, Sweden.
¹¹ Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Denmark.
¹² Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
¹³ South Western Clinical School, University of New South Wales, Sydney, Australia; Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, Australia.
¹⁴ Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland. Electronic address: markus.skrifvars@hus.fi.

PMID: 37295549
DOI: 10.1016/j.resuscitation.2023.109862

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 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.

Keywords: Blood pressure; Cardiac arrest; Meta-analysis; Systematic review; Target.

Publication types

Systematic Review
Meta-Analysis
Review

MeSH terms

Blood Pressure / physiology
Heart Arrest*
Humans