Should We Match Blood Pressure to Each Patient's Baseline in Cardiac Surgery?
A lot of cardiac surgery patients live with high blood pressure at home. In the OR we often aim for a mean arterial pressure of at least 65 mm Hg and move on. The OPTIPAM trial, published in Anesthesiology on November 6, 2026, asked whether chasing each patient's own preoperative baseline instead would cut death, kidney injury, or neurologic trouble. The answer is not reassuring, and the bleeding signal is hard to ignore.
The study
Descamps and colleagues ran a single-blind, multicenter randomized trial across 10 tertiary centers in France. Adults having elective cardiac surgery with cardiopulmonary bypass were assigned either to individualized MAP management (target within about 10% of the preoperative baseline during surgery and for 24 hours afterward) or to standard management (MAP at least 65 mm Hg). The primary outcome was a composite of all-cause death, acute kidney injury, or prespecified neurologic complications within seven days. Safety outcomes included bleeding and transfusion.
The trial stopped early after 172 patients because of excess bleeding in the individualized arm. Mean intraoperative MAP was higher with individualized targets (80.6 versus 75.6 mm Hg), though target adherence was limited (about one third of intraoperative time) and vasopressor use was higher. The primary outcome occurred in 27 of 85 patients (32%) with individualized management and 25 of 87 (29%) with standard care (relative risk 1.1; 95% CI 0.7 to 1.8). Hemorrhagic complications were more common in the individualized group (18% versus 3%).
How I read it
Individualizing MAP sounds right on paper. Match the pressure the brain and kidneys are used to, and maybe you spare organs. OPTIPAM could not show that benefit, and the early stop for bleeding leaves us without a clean answer on the primary endpoint. Higher pressures driven by more vasopressors may not be free. Surgical sites and suture lines care about the pressure you push against as much as the organs care about perfusion.
Adherence was also modest. Holding a narrow band around baseline through bypass and the first postoperative day is hard in real rooms. If the strategy is difficult to deliver even in a trial, that matters when we talk about adopting it.
What it means for practice here
For cardiac cases that come through Casper and the surrounding region, I am not changing my default floor of about 65 mm Hg based on OPTIPAM. I still think about a patient's home pressures, especially when someone is markedly hypertensive at baseline, but I will not chase a tight individualized band with more norepinephrine just because a protocol says so. Protecting kidneys and the brain still starts with adequate flow, hemoglobin, and avoiding prolonged deep hypotension. Until a larger trial clarifies both benefit and the bleeding risk, individualized MAP targets in cardiac surgery stay investigational, not routine.
Source
- Descamps R, Mertes PM, Charvin M, et al. Individualized mean arterial pressure during cardiac surgery: the OPTIPAM randomized clinical trial. Anesthesiology. Published November 6, 2026. doi:10.1097/ALN.0000000000006471. Full text (DOI)
This post is clinician commentary for educational discussion. It is not medical advice for any reader's personal care. Anesthesia and perioperative decisions should be made with the treating clinician based on the individual patient's circumstances.