High blood pressure-targeted management associated with reduced benefits of higher body mass index in elderly patients with septic shock: a post hoc analysis of a multicenter randomized controlled trial
In brief
Higher body mass index linked to lower mortality only at standard pressure targets
In a post hoc analysis of 489 older adults with septic shock, 90-day mortality fell across higher body mass index groups under the standard blood pressure target, but not under the higher target. Higher-BMI patients in the high-target group had greater mortality than normal-weight patients; the observational subgroup finding does not establish why, but suggests blood pressure strategy may modify this association.
- Journal
- Annals of intensive care (Q1)
- Published
- 14 September 2026
- Study design
- Randomized controlled trial
- Evidence level
- Level 1, High (CEBM 1b)
- Authors
- Takashi Shimazui, Tadanaga Shimada, Takehiko Oami, Akira Endo, Kazuma Yamakawa, Takashi Tagami, et al.
- PMID
- 42831066
- DOI
- 10.1016/j.aicoj.2026.100157
Why clinicians should know about it
- Picked for Critical Care and Intensive Care Medicine (paper of the day, 6 October 2026): MAP target strategy significantly interacted with higher-BMI category
Abstract
BACKGROUND: Body mass index (BMI) is an important prognostic factor in sepsis, and an obesity paradox has been reported. A higher mean arterial pressure (MAP) target has been associated with worse outcomes in elderly patients with septic shock. However, whether MAP target strategy alters the association between BMI and outcomes in this population is unknown. METHODS: We conducted a post hoc analysis of the OPTPRESS trial, a multicenter randomized controlled trial at 29 Japanese centers reporting worse outcomes with a high MAP target in elderly patients with septic shock. A total of 489 patients aged ≥65 years with septic shock were assigned to a control MAP target of 65-70 mmHg (n = 245) or high target of 80-85 mmHg (n = 244). Patients were categorized using Asian BMI cutoffs into underweight (<18.5 kg/m2), normal-weight (18.5-22.9 kg/m2), and higher-BMI (≥23 kg/m2) categories. The primary outcome was 90-day mortality. The primary analysis assessed the interaction between BMI category and MAP target strategy. RESULTS: In the control group, mortality decreased across increasing BMI categories (P = 0.03 for the trend), while no trend was observed in the high-target group (P = 0.26 for the trend). After adjustment for age, sex, APACHE II score, Clinical Frailty Scale, and site of infection, MAP target strategy significantly interacted with the higher-BMI category (P = 0.02), but not with underweight (P = 0.41). In the high-target group, both underweight and higher-BMI patients had higher mortality than those with normal BMI (underweight, adjusted HR 1.74 [95% CI 1.02-2.98], P = 0.04; higher BMI, adjusted HR 1.72 [95% CI 1.02-2.87], P = 0.04). Fluid volume per body weight decreased across increasing BMI categories in both groups. The proportion of patients receiving vasopressin increased across BMI categories only in the control group, whereas the body weight-adjusted vasopressin dose among recipients showed no significant trend in either group. CONCLUSIONS: In elderly patients with septic shock, mortality decreased across increasing BMI categories under a standard MAP target, whereas patients in the higher-BMI category had higher mortality under a high MAP target. High MAP targets may attenuate the survival benefit of higher BMI, possibly in association with BMI-related patterns in fluid and vasopressor management. TRIAL REGISTRATION: Not registered. The original OPTPRESS trial was registered at UMIN Clinical Trials Registry (UMIN000041775) on 13 September 2020.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.