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Kotani, Y., Lezzi, M., Murru, C. P., et al. | J Cardiothorac Vasc Anesth (2025) 39(3):653-665 | The efficacy and safety of angiotensin ii for treatment of vasoplegia in critically ill patients: A systematic review

November 29, 2025

Objective: To summarize the available evidence regarding intravenous angiotensin II administration in critically ill patients and provide an updated understanding of its effects on organ dysfunction and renin-angiotensin system (RAS) biomarkers.

Methods: A systematic review was conducted using PubMed, Embase, and the Cochrane Library from database inception to May 3, 2024. Eligible studies included randomized controlled trials (RCTs), nonrandomized trials, quasi-randomized trials, observational studies, case reports, and case series evaluating intravenous angiotensin II in critically ill adults and children. Comparative studies (RCTs and observational studies with control groups) were included in the primary analysis.

Results: Fifty-nine studies involving 2,918 participants were included, comprising 5 randomized controlled trials, 15 observational studies, and 39 case reports or case series. Septic shock and cardiac surgery were the most common clinical indications, each represented by 14 studies. Across 14 comparative studies (5 RCTs and 9 observational studies), mortality did not differ significantly between angiotensin II and control groups, except in one observational study. Several studies reported reduced need for renal replacement therapy, improved blood pressure and oxygenation, and lower rates of myocardial injury with angiotensin II treatment. No increase in thrombotic complications or other adverse events was observed. Angiotensin II therapy reduced circulating renin and angiotensin I concentrations without significantly affecting other RAS biomarkers.

Conclusions: Intravenous angiotensin II has been studied in nearly 3,000 critically ill patients with various forms of shock. Although its effect on mortality remains uncertain, angiotensin II appears to provide beneficial effects on hemodynamic stability, organ function, and renin-angiotensin system abnormalities without increasing adverse events.

Keywords: systematic review; angiotensin II; septic shock; vasoplegia; vasoconstrictor agents; renin-angiotensin system.