UMEM Educational Pearls

Category: Critical Care

Title: Targeting Better Neurologic Outcomes by Targeting Higher MAPs Post-Cardiac Arrest

Keywords: resuscitation, cardiac arrest, post-cardiac arrest care, blood pressure, MAP, ROSC (PubMed Search)

Posted: 11/5/2018 by Kami Hu, MD (Emailed: 11/6/2018) (Updated: 11/6/2018)
Click here to contact Kami Hu, MD

The most recent AHA guidelines for goal blood pressure after return of spontaneous circulation (ROSC) post-cardiac arrest recommend a definite mean arterial pressure (MAP) goal of > 65 mmHg.1 There is no definitive data to recommend a higher specific goal, but there is some evidence to indicate that maintaining higher MAPs may be associated with better neurologic outcomes.2

A recently published prospective, observational, multicenter cohort study looked at neurologic outcomes corresponding to different MAPs maintained in the initial 6 hours post-cardiac arrest.3

Findings: 

1. Compared to lower blood pressures (MAPs 70-90 mmHg), the cohort with MAPs > 90 mmHg had:

  • a higher rate of good neurologic function at hospital discharge (42 vs.15%, p < 0.001)
  • a higher rate of survival to 72 hours (86 vs. 74%, p=0.01) and hospital discharge (57 vs 28%, p < 0.001)

2. The association between MAP > 90 mmHg and good neurologic outcome was stronger among patients with a previous diagnosis of hypertension, and persisted regardless of initial rhythm, use of vasopressors, or whether the cardiac arrest occured in or out of hospital.

3. There was a dose-response increase in probability of good neurologic outcome among all MAP ranges above 90 mmHg, with MAP >110 mmHg having the strongest association with good neurologic outcome at hospital discharge.

Note: The results of a separate trial, the Neuroprotect post-CA trial, comparing MAPs 85-100 mmHg to the currently recommended MAP goal of >65 mmHg, are pending.4

 

Bottom Line: As per current AHA guidelines, actively avoid hypotension, and consider use of vasopressor if needed to maintain MAPs > 90 mmHg in your comatose patients post-cardiac arrest, especially those with a preexisting diagnosis of hypertension.

 

References

  1. Callaway CW, Donnino MW, Fink EL, et al: Part 8: Post-cardiac arrest care: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132:S465–S482.
  2. Beylin ME, Perman SM, Abella BS, et al. Higher mean arterial pressure with or without vasoactive agents is associated with increased survival and better neurological outcomes in comatose survivors of cardiac arrest. Intensive Care Med. 2013;39(11):1981-8.
  3. Roberts BW, Kilgannon JH, Hunter BR, et al. Association between elevated mean arterial blood pressure and neurologic outcome after resuscitation from cardiac arrest: results for a multicenter prospective cohort study. Crit Care Med. 2018; doi:10.1097/CCM.0000000000003474. [Epub ahead of print].
  4. Ameloot K, De Deyne C, Ferdinande B, et al. Mean arterial pressure of 65 mmHg versus 85-100 mmHg in comatose survivors after cardiac arrest: Rationale and study design of the Neuroprotect post-cardiac arrest trial. Am Heart J. 2017;191:91-8.