Haemodynamic monitoring during cardiac arrest: a systematic review of diastolic blood pressure and coronary perfusion pressure

OBJECTIVE: To evaluate whether intra-arrest diastolic blood pressure (DBP) and coronary perfusion pressure (CPP) are associated with improved return of spontaneous circulation (ROSC) in cardiac arrest. METHODS: A systematic search (PROSPERO registration: CRD420251042344) was conducted in English on EMBASE, MEDLINE, CINAHL and the Cochrane Library from inception to 1 May 2025. Grey literature sources (trial registries, conference abstracts, Google Scholar) were searched. Key resuscitation experts were contacted to identify unpublished or ongoing studies. The search strategy was peer-reviewed using the Peer Review of Electronic Search Strategies checklist. Eligible studies included randomised controlled trials (RCTs) contributing cohort data, observational studies and case series (≥10 patients) monitoring intra-arrest DBP or CPP in adult patients with cardiac arrest managed in prehospital or emergency department settings. Study selection involved two reviewers independently screening titles and abstracts, and full-text articles. Risk of bias was assessed using the Risk of Bias 2 and Risk of Bias in Non-randomised Studies of Interventions tools. This research received no funding. RESULTS: identified a DBP threshold of 35 mm Hg associated with ROSC (p<0.001), reporting a 5% increase in ROSC odds for every 1 mm Hg rise in DBP. This finding was supported by other observational studies reporting significantly higher maximum DBP values in patients with ROSC (34-56.5 mm Hg) compared with those without ROSC. Interventional studies aimed at augmenting DBP or CPP-including resuscitative endovascular balloon occlusion of the aorta-generally reported increases in ROSC, though studies were underpowered and at high risk of bias. CONCLUSIONS: This review demonstrates an association between intra-arrest DBP and CPP and ROSC. DBP may provide a feasible clinical target, but definitive thresholds and their impact on survival to hospital discharge remain undefined. PROSPERO REGISTRATION NUMBER: CRD420251042344.