Written by Catherine Burger
This randomized control trial of older ICU patients with septic shock in Japan showed higher mortality and more frequent adverse events in patients randomized to a high MAP goal (80-85 mmHg) compared to usual care (65-70 mmHg).
Hypertension is bad for you…even when you have septic shock
Authors enrolled patients ≥ 65 years with septic shock to 29 ICUs in Japan. Patients were randomized to a high mean arterial pressure (MAP) goal of 80-85 mmHg or usual care – MAP goal of 65-70 mmHg – for 72 hours or until vasopressors were no longer needed. Prevalence of hypertension in the Japanese population is 70% in those ≥ 65 years. If the MAP goal could not be achieved by a norepinephrine dose of ≥ 0.1 mcg/kg/min, vasopressin was initiated. If still not reached, they could increase norepinephrine, add another vasopressor, or add hydrocortisone. Other care was at the discretion of the treatment team. The primary outcome was 90-day all-cause mortality, while secondary outcomes were organ-support-free days and adverse events.
Authors planned to enroll 836 patients; however, interim analysis indicated that the high target MAP group met predefined termination criteria for ineffectiveness and suggested harm, so enrollment was discontinued. A total of 258 patients were randomized to the high target MAP group and 260 to usual care. Higher MAPs (and higher vasopressor doses) were achieved in the high MAP group vs usual care. All-cause 90-day mortality in the high MAP group was 39.3% vs. 28.6% in usual care, a difference of 10.7% (95%CI 2.6% to 18.9%). Additionally, no clinical benefit of the high target MAP strategy was seen for any outcome or subgroup, including those with known hypertension. More adverse safety events (arrhythmia, ischemic events, hemorrhagic events) were seen in the high target MAP group.
How does this change my practice?
I will cautiously avoid persistently elevated MAPs (beyond 70 mmHg) in those with septic shock receiving vasopressors in the ED, especially older patients.
Source
Efficacy of targeting high mean arterial pressure for older patients with septic shock (OPTPRESS): a multicentre, pragmatic, open-label, randomised controlled trial. Intensive Care Med. 2025 May;51(5):883-892. doi: 10.1007/s00134-025-07910-4. Epub 2025 May 13. PMID: 40358717
