Efficacy of targeting high mean arterial pressure for older patients with septic shock (OPTPRESS): a multicentre, pragmatic, open-label, randomised controlled trial.

Summary

In older ICU patients with septic shock, targeting MAP 80–85 mmHg increased 90-day mortality by an absolute 10.7% compared with 65–70 mmHg, and reduced renal replacement therapy–free days. No subgroup, including those with chronic hypertension, benefited from higher targets.

Key Findings

• High MAP target (80–85 mmHg) increased 90-day all-cause mortality versus 65–70 mmHg (39.3% vs 28.6%; absolute risk difference 10.7%, 95% CI 2.6–18.9).
• Renal replacement therapy–free days at 28 days were fewer in the high-target group, indicating worse kidney-related outcomes.
• No subgroup, including patients with known chronic hypertension, derived clinical benefit from higher MAP targets.

Clinical Implications

For older patients with septic shock, maintain MAP targets at 65–70 mmHg rather than 80–85 mmHg. Avoid escalation to high MAP targets even in patients with chronic hypertension; reconsider protocols and decision support to prevent overtitration of vasopressors.

Limitations

• Open-label design may introduce performance bias, although mortality is a hard endpoint.
• Conducted in one country; external generalizability to other healthcare systems may require validation.

Future Directions

Evaluate mechanisms underpinning harm at higher MAP (e.g., microcirculatory effects, organ-specific injury) and assess individualized targets incorporating frailty or vascular pathology. Validate findings in diverse health systems.