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

Summary

In a multicenter pragmatic RCT of 518 patients ≥65 years with septic shock, targeting MAP 80–85 mmHg increased 90-day mortality versus 65–70 mmHg (39.3% vs 28.6%; risk difference 10.7%). No subgroup benefited, including those with chronic hypertension; renal replacement therapy–free days were fewer with the high-MAP strategy.

Key Findings

• 90-day all-cause mortality was higher with MAP 80–85 mmHg vs 65–70 mmHg (39.3% vs 28.6%; 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.
• No subgroup, including patients with chronic hypertension, derived benefit from a higher MAP target.
• Trial was stopped early for harm based on interim analysis.

Clinical Implications

Avoid targeting MAP 80–85 mmHg in elderly septic shock; standard targets of 65–70 mmHg should be preferred. Monitor for potential renal support needs when higher vasopressor targets are considered.

Limitations

• Open-label design may introduce performance bias
• Generalizability primarily to older Japanese ICU population; target maintained for first 72 hours

Future Directions

Assess individualized MAP targets integrating frailty, vascular stiffness, and microcirculatory endpoints; evaluate downstream renal and cardiovascular adverse effects of higher vasopressor exposure.