BACKGROUND: In patients resuscitated after cardiac arrest, a higher mean arterial pressure (MAP) may increase cerebral perfusion and attenuate hypoxic brain injury. Here we present the protocol of the mean arterial pressure after cardiac arrest and resuscitation (MAP-CARE) trial aiming to investigate the influence of MAP targets on patient outcomes. METHODS: MAP-CARE is one component of the Sedation, Temperature and Pressure after Cardiac Arrest and Resuscitation (STEPCARE) 2 x 2 x 2 factorial randomized trial. The MAP-CARE trial is an international, multicenter, parallel-group, investigator-initiated, superiority trial designed to test the hypothesis that targeting a higher (>85 mmHg) (intervention) versus a lower (>65 mmHg) (comparator) MAP after resuscitation from cardiac arrest reduces 6-month mortality (primary outcome). Trial participants are adults with sustained return of spontaneous circulation who are comatose following resuscitation from out-of-hospital cardiac arrest. The two other components of the STEPCARE trial evaluate sedation and temperature control strategies. Apart from the STEPCARE trial interventions, all other aspects of general intensive care will be according to the local practices of the participating site. Neurological prognostication will be performed according to European Resuscitation Council and European Society of Intensive Care Medicine guidelines by a physician blinded to allocation group. The sample size of 3500 participants provides 90% power with an alpha of 0.05 to detect a 5.6 absolute risk reduction in 6-month mortality, assuming a mortality of 60% in the control group. Secondary outcomes will be poor functional outcome 6 months after randomization, patient-reported overall health 6 months after randomization, and the proportion of participants with predefined severe adverse events. CONCLUSION: The MAP-CARE trial will investigate if targeting a higher MAP compared to a lower MAP during intensive care of adults who are comatose following resuscitation from out-of-hospital cardiac arrest reduces 6-month mortality.

2nd Department of Internal Medicine Cardiovascular Medicine General University Hospital 1st Faculty of Medicine Charles University Prague Prague Czech Republic

2nd Department of Medicine Department of Cardiovascular Medicine 1st Faculty of Medicine Charles University Prague General University Hospital Prague Prague Czech Republic

Adult Critical Care University Hospital of Wales Cardiff UK

Anaesthesia and Intensive Care Pordenone Hospital Azienda Sanitaria Friuli Occidentale Pordenone Italy

Anesthesia and Intensive Care Department of Clinical Sciences Lund Lund University Lund Sweden

Anesthesia and Intensive Care Department of Clinical Sciences Lund Lund University Skane University Hospital Lund Sweden

Anesthesia and Intensive Care Department of Clinical Sciences Lund University Skane University Hospital Malmö Sweden

Anglia Ruskin School of Medicine ARU Essex UK

Australian and New Zealand Intensive Care Research Centre Monash University Melbourne Victoria Australia

Bristol Royal Infirmary University Hospitals Bristol and Weston Bristol UK

Caboolture and Royal Brisbane and Women's Hospitals Metro North Hospital and Health Service Brisbane Queensland Australia

CEDAR Cardiff and Vale University Health Board Cardiff Cardiff UK

Copenhagen Trial Unit Centre for Clinical Intervention Research Copenhagen University Hospital Rigshospitalet Copenhagen Denmark

Critical Care Division Department of Intensive Care Medicine The George Institute for Global Health Sydney Australia

Critical Care Division The George Institute for Global Health University of New South Wales Sydney New South Wales Australia

Critical Care Program The George Institute for Global Health UNSW Sydney Australia

Department of Anaesthesia and Intensive Care Helsinki University Hospital and University of Helsinki Helsinki Finland

Department of Anaesthesia and Intensive Care Jorvi Hospital University Hospital of Helsinki and University of Helsinki Helsinki Finland

Department of Anaesthesia and Intensive Care Medicine Centre Hospitalier de Luxembourg Luxembourg Luxembourg

Department of Anaesthesiology and Intensive Care Kuopio University Hospital Kuopio Finland

Department of Anaesthesiology and Intensive Care Medicine Institute of Clinical Sciences Sahlgrenska Academy University of Gothenburg Gothenburg Sweden

Department of Anesthesia and Intensive Care Helsingborg Hospital Helsingborg Sweden

Department of Anesthesia and Intensive Care Medicine Division of Emergencies and Critical care Oslo University Hospital Oslo Norway

Department of Anesthesia Critical Care and Pain Medicine Jaber Alahmad Alsabah Hospital Kuwait

Department of Cardiology Royal Prince Alfred Hospital Sydney New South Wales Australia

Department of Cardiology Ziekenhuis Oost Limburg Genk Belgium

Department of Clinical Science Intervention and Technology Karolinska Institute Stockholm Sweden

Department of Clinical Sciences Anesthesia and Intensive Care Lund University Skåne University Hospital Malmö Sweden

Department of Clinical Sciences Lund Anesthesia and Intensive Care Lund University Lund Sweden

Department of Clinical Sciences Lund Lund University Lund Sweden

Department of Clinical Sciences Lund Section of Cardiology Skåne University Hospital Lund Sweden

Department of Critical Care Portsmouth University Hospitals Trust Cosham Portsmouth UK

Department of Critical Care University of Melbourne Melbourne Victoria Australia

Department of Intensive and Perioperative Care Skåne University Hospital Lund University Lund Sweden

Department of Intensive Care Christchurch Hospital Christchurch New Zealand

Department of Intensive Care Medicine Ghent University Hospital Ghent Belgium

Department of Intensive Care Medicine Inselspital University Hospital Bern Bern Switzerland

Department of Intensive Care Medicine Stavanger University Hospital Stavanger Norway

Department of Life Sciences and Medicine Faculty of Science Technology and Medicine University of Luxembourg Esch sur Alzette Luxembourg

Department of Nephrology and Medical Intensive Care Charité Universitaetsmedizin Berlin Berlin Germany

Department of Neurology and Rehabilitation Skåne University Hospital Lund Sweden

Department of Neurology and Stroke University Hospital Tuebingen Tuebingen Germany

Department of Neurology Freie Universität and Humboldt Universität zu Berlin Charité Universitätsmedizin Berlin Berlin Germany

Department of Neurology Helsinki University Hospital and University of Helsinki Helsinki Finland

Department of Neurology Skåne University Hospital Lund Sweden

Department of Operation and Intensive Care Hallands Hospital Halmstad Halmstad Sweden

Department of Perioperative Medicine Barts Heart Centre St Bartholomew's Hospital London UK

Department of Physiology and Pharmacology Karolinska Institutet Stockholm Sweden

Department of Regional Health Research Faculty of Health Sciences University of Southern Denmark Copenhagen Denmark

Department of Research Development Education and Innovation Skåne University Hospital Lund Sweden

Dipartimento di Scienze Chirurgiche Diagnostiche Integrate University of Genova Genova Italy

Division of Intensive Care and Emergency Medicine Department of Internal Medicine Medical University Insbruck Innsbruck Austria

Essex Cardiothoracic Centre Essex UK

German Center for Cardiovascular Research partner site Hamburg Lübeck Kiel Germany

Guy's and St Thomas' Hospital London UK

Hertie Institute of Clinical Brain Research Tuebingen Germany

Institute for Heart Diseases Wroclaw Medical University Wrocław Poland

Institute of Clinical Medicine University of Eastern Finland Kuopio Finland

Institute of Intensive Care Medicine University Hospital Zurich Zurich Switzerland

Intensive and Perioperative Care Skåne University Hospital Malmö Sweden

Intensive Care Medicine Centre for Human and Applied Physiological Sciences School of Basic and Medical Biosciences Faculty of Life Sciences Medicine King's College London UK

Intensive Care Medicine King's Critical Care King's College Hospital NHS Foundation Trust London UK

Intensive Care Unit John Hunter Hospital Newcastle New South Wales Australia

Intensive Care Unit Liverpool Hospital South Western Sydney Local Health District Sydney New South Wales Australia

Intensive Care Unit Tampere University Hospital Tampere Finland

Intensive Care Unit Wellington Hospital Wellington New Zealand

IRCCS Policlinico San Martino Genoa Italy

Istituto Cardiocentro Ticino Lugano Switzerland

King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center Riyadh Saudi Arabia

Klinik für Intensivmedizin Kantonsspital St Gallen St Gallen Switzerland

Lee Kong Chian School of Medicine Nanyang Technological University Singapore Singapore

Leeds Teaching Hospitals NHS Trust Leeds UK

Liverpool Hospital Sydney New South Wales Australia

Lovisenberg Diaconal University College Oslo Norway

Malcolm Fisher Department of Intensive Care Royal North Shore Hospital Sydney New South Wales Australia

Medical Research Institute of New Zealand Wellington New Zealand

Middlemore Hospital Auckland New Zealand

Neurology Department of Clinical Sciences Lund Lund University Lund Sweden

North Estonia Medical Centre Tallinn Estonia

Northern Clinical School Sydney Medical School University of Sydney Sydney New South Wales Australia

OYS Heart Oulu University Hospital MRC Oulu and University of Oulu Oulu Finland

Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden

Regional Intensive Care Unit Royal Victoria Hospital Belfast UK

Research Unit of Translational Medicine Research Group of Anaesthesiology Medical Research Center Oulu Oulu University Hospital and University of Oulu Oulu Finland

Royal North Shore Hospital Sydney Australia

School of Clinical Medicine Queensland University of Technology Brisbane Queensland Australia

School of Medicine and Public Health University of Newcastle Newcastle New South Wales Australia

South Western Clinical School University of New South Wales Sydney New South Wales Australia

St George Hospital Clinical School University of New South Wales Sydney New South Wales Australia

St George's University Hospital NHS Foundation Trust London UK

Tan Tock Seng Hospital Singapore Singapore

The Alfred Hospital Melbourne Australia

The George Institute for Global Health Sydney Australia

The Ingham Institute for Applied Medical Research Sydney New South Wales Australia

University College Dublin Clinical Research Centre at St Vincent's University Hospital University College Dublin Dublin Ireland

University Hospital Schleswig Holstein University Heart Center Lübeck Lübeck Germany

Wellbeing Services County of Pirkanmaa and Tampere University Faculty of Medicine and Health Technology Tampere University Hospital Tampere Finland

Wellcome Wolfson Institute for Experimental Medicine Queen's University Belfast Belfast UK

Yong Loo Lin School of Medicine National University of Singapore Singapore Singapore

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