Reevaluating Mean Arterial Pressure Targets in Vasodilatory Shock: Implications for Emergency Care

A recent systematic review and meta-analysis identified a mortality signal when comparing higher versus lower mean arterial pressure (MAP) targets in vasodilatory shock. Pooled trials showed worse outcomes with higher targets, directly challenging routine early resuscitation strategies that default to higher MAP goals.

Across four randomized trials (total n = 3,873), a higher MAP target was associated with an ~10% relative increase in 28‑day all‑cause mortality (risk ratio ≈ 1.10; 95% CI 1.01–1.19) using random‑effects models and complementary Bayesian analysis. The primary endpoint across trials was 28‑day mortality, and the pooled estimate remained statistically significant despite between‑trial heterogeneity—supporting caution about one‑size‑fits‑all MAP targets.

Subgroup analyses showed treatment effect modification by patient factors. Older age and chronic comorbidities (longstanding hypertension, ischemic heart disease, chronic kidney disease) altered the association between MAP target and outcomes. These signals suggest a need for phenotype‑driven individualization of MAP goals rather than blanket escalation for all patients.

Non‑mortality outcomes also favored the lower MAP target groups, with fewer arrhythmias and a small reduction in days requiring renal replacement therapy. This pattern plausibly reflects reduced catecholamine exposure from less aggressive vasopressor titration, translating into fewer rhythm disturbances and less drug‑related renal insult—further supporting restrained vasopressor escalation when lower MAPs are clinically tolerated.