Angiotensin II in the treatment of distributive shock and identification of clinical profiles with greater therapeutic benefit.

The cornerstone of vasopressor treatment for distributive shock is norepinephrine; however, the administration of high doses is associated with significant adrenergic toxicity and increased morbidity and mortality. Angiotensin II, a recently approved physiological alternative to norepinephrine within a multimodal vasopressor strategy, has the advantage of rebalancing the renin-angiotensin-aldosterone system and reducing catecholamine doses. This review analyses the role of angiotensin II in distributive shock, exploring its pharmacodynamic characteristics and its impact on haemodynamic stability. The evidence collected to date has identified specific groups that derive clinical benefit, particularly patients with acute kidney injury, acute respiratory distress syndrome, or prior exposure to renin-angiotensin system inhibitors (angiotensin-converting enzyme inhibitors). Dynamic assessment tools, such as the AIMRITE (Angiotensin-II Initial MAP Response Index of Treatment Effect) index, may be useful for assessing early response to angiotensin II and supporting therapeutic decisions at an early stage. Ultimately, angiotensin II allows clinicians to implement personalised, safe therapeutic measures that are tailored to the complexity of the critically ill patient.