Hemodynamic management of cardiogenic shock following ischemic out-of-hospital cardiac arrest (OHCA-AMICS) remains an unresolved issue, particularly regarding optimal mean arterial pressure (MAP) targets and the use of vasoactive agents such as norepinephrine. This substudy of the BOX trial evaluated the impact of different MAP targets on hemodynamic parameters and clinical outcomes.
Patients from the BOX trial meeting criteria for cardiogenic shock were analyzed, comparing a lower MAP target (63 mmHg) versus a higher MAP target (77 mmHg) in a randomized, double-blind design. A total of 789 patients were included, and invasive hemodynamic parameters were assessed using a Swan-Ganz catheter.
From a hemodynamic standpoint, the higher MAP group showed a greater cardiac index and higher mixed venous oxygen saturation (SvO₂). However, these improvements were achieved at the cost of higher norepinephrine doses, with a consequent increase in afterload and potential adverse myocardial effects.
Despite these physiological differences, no improvements were observed in tissue perfusion parameters (lactate) or in clinically relevant outcomes. One-year mortality was similar between groups (26% vs 34%; HR 0.70; 95% CI 0.45–1.10), with no differences in the need for renal replacement therapy or neurological outcomes.
An additional finding was the increase in ventricular filling pressures in the higher MAP group, likely related to greater fluid administration and the hemodynamic effects of norepinephrine.
Conclusion
In patients with cardiogenic shock after OHCA, a strategy targeting a higher mean arterial pressure improves certain hemodynamic parameters but does not translate into meaningful clinical benefit.
Presented by Sanne ten Berg at the Acute Cardiovascular Care Congress 2026, Lisbon, Portugal, March 20–21, 2026.
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