What is the optimal range for mean arterial pressure (MAP) in adults, particularly those with hypertension, heart failure, or critical illness?

Optimal Mean Arterial Pressure Targets in Adults

Standard MAP Target for Most Adults

For the vast majority of critically ill adults, including those with sepsis, shock, or requiring vasopressors, target a MAP of 65 mmHg as the initial goal. 1, 2, 3 This threshold represents the critical point below which organ autoregulation fails and tissue perfusion becomes linearly dependent on arterial pressure. 2, 3

• The Surviving Sepsis Campaign strongly recommends this 65 mmHg target as it balances adequate organ perfusion while minimizing risks of arrhythmias and excessive vasopressor requirements. 1, 2, 3
• Randomized controlled trials involving 3,690 patients demonstrated no mortality benefit from targeting higher MAP values (75-85 mmHg) compared to 65 mmHg in general critically ill populations. 4, 5
• Post-cardiac arrest patients should target MAP 60-65 mmHg, as higher targets (71+ mmHg) showed no benefit for survival or neurological outcomes at 180 days. 1

Critical Adjustments for Chronic Hypertension

Patients with documented chronic hypertension require a higher MAP target of 70-85 mmHg. 2, 3, 6

• Their autoregulation curve is shifted rightward, meaning they need higher pressures to maintain organ perfusion, particularly renal perfusion. 2, 3
• Meta-analysis shows that targeting MAP 75-85 mmHg in chronically hypertensive patients reduces the need for renal replacement therapy (RR 0.83,95% CI 0.71-0.98). 5
• One randomized trial specifically targeting MAP 80-95 mmHg in hypertensive surgical patients showed reduced acute kidney injury (6.3%) compared to lower targets (13.5%). 1

Age-Based Modifications

For elderly patients over 75 years, target a lower MAP of 60-65 mmHg. 2, 3, 6

• A pilot trial of 118 elderly septic shock patients suggested reduced mortality with MAP targets of 60-65 mmHg compared to 75-80 mmHg. 2, 3
• This permissive hypotension strategy in older adults balances perfusion needs against risks of excessive vasopressor exposure. 3

Special Clinical Scenarios Requiring Higher Targets

Spinal cord injury patients need MAP ≥70 mmHg during the first week post-injury to prevent neurological deterioration. 2

Patients with elevated intra-abdominal pressure (>12 mmHg) require higher MAP targets to compensate for reduced organ perfusion pressure. 2, 3

• Trans-kidney perfusion pressure (MAP minus central venous pressure) should exceed 60 mmHg in heart failure or fluid-overloaded patients. 2, 3
• When CVP is elevated, simply achieving MAP 65 mmHg may be insufficient—calculate actual perfusion pressure as MAP - CVP. 2

Post-cardiac arrest patients with suspected elevated intracranial pressure may benefit from MAP >100 mmHg during the first 2 hours after return of spontaneous circulation, though this is based on observational data. 2

Perioperative Blood Pressure Management

Maintain intraoperative MAP ≥60-65 mmHg or systolic blood pressure >90 mmHg. 2

• Harm thresholds appear around MAP <65 mmHg maintained for approximately 15 minutes during surgery. 2
• For hypertensive surgical patients, maintain MAP within 10% of baseline or target MAP >70 mmHg specifically to preserve renal perfusion. 1, 2

Monitoring Beyond MAP Alone

MAP is necessary but insufficient—simultaneously monitor these perfusion markers: 2, 3

• Urine output: Goal >0.5 mL/kg/hour 2, 3
• Lactate clearance: Trending downward 2, 3
• Mental status: Alertness and orientation 2, 3
• Skin perfusion: Capillary refill time <3 seconds 2, 3
• Creatinine trends: Stable or improving 2

Vasopressor Management Algorithm

When MAP remains <65 mmHg after adequate fluid resuscitation: 3, 6

1. Start norepinephrine at 0.01-0.5 μg/kg/min as first-line agent 3, 6
2. Titrate to MAP ≥65 mmHg (or higher target if chronically hypertensive) 1, 3, 6
3. Add vasopressin (up to 0.03 U/min) as second-line if MAP target not achieved with norepinephrine alone 1, 3, 6
4. Consider dobutamine if cardiac dysfunction and persistent hypoperfusion despite adequate MAP 1

Common Pitfalls to Avoid

Do not assume MAP 65 mmHg is universally adequate. 2, 3 Chronic hypertension, elevated CVP, increased intra-abdominal pressure, and spinal cord injury all require individualized higher targets.

Do not rely on MAP alone without assessing tissue perfusion markers. 2, 3 Blood pressure does not necessarily reflect cardiac output or adequate tissue perfusion.

Do not target MAP >85 mmHg in general populations. 3, 6 This significantly increases risk of arrhythmias without mortality benefit.

Do not use central venous pressure alone to guide fluid resuscitation. 3 CVP poorly predicts fluid responsiveness but is essential for calculating trans-organ perfusion pressure.

In pregnant/postpartum patients (20 weeks gestation through 3 days postpartum), use systolic blood pressure <85 mmHg as the threshold rather than <90 mmHg. 2