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Marcucci M, Painter TW, Conen D, Lomivorotov V, Sessler DI, Chan MTV, Borges FK, Leslie K, Duceppe E, Martinez-Zapata MJ, Wang CY, Xavier D, Ofori SN, Wang MK, Efremov S, Landoni G, Kleinlugtenbelt YV, Szczeklik W, Schmartz D, Garg AX, Short TG, Wittmann M, Meyhoff CS, Amir M, Torres D, Patel A, Ruetzler K, Parlow JL, Tandon V, Fleischmann E, Polanczyk CA, Lamy A, Jayaram R, Astrakov SV, Wu WKK, Cheong CC, Ayad S, Kirov M, de Nadal M, Likhvantsev VV, Paniagua P, Aguado HJ, Maheshwari K, Whitlock RP, McGillion MH, Vincent J, Copland I, Balasubramanian K, Biccard BM, Srinathan S, Ismoilov S, Pettit S, Stillo D, Kurz A, Belley-Cote EP, Spence J, McIntyre WF, Bangdiwala SI, Guyatt G, Yusuf S, Devereaux PJ, Investigators P-T, Study G: Hypotension-avoidance versus hypertension-avoidance strategies in noncardiac surgery : An international randomized controlled trial. Ann Intern Med 2023; 176: 605-614

August 20, 2023

Background:
Among patients having noncardiac surgery, perioperative hemodynamic abnormalities are associated with vascular complications. Uncertainty remains about what intraoperative blood pressure to target and how to manage long-term antihypertensive medications perioperatively.
Objective:
To compare the effects of a hypotension-avoidance and a hypertension-avoidance strategy on major vascular com- plications after noncardiac surgery.
Design:
Partial factorial randomized trial of 2 perioperative blood pressure management strategies (reported here) and tra- nexamic acid versus placebo. (ClinicalTrials.gov: NCT03505723)
Setting: 110 hospitals in 22 countries.
Patients:
7490 patients having noncardiac surgery who were at risk for vascular complications and were receiving 1 or more long-term antihypertensive medications.
Intervention:
In the hypotension-avoidance strategy group, the intraoperative mean arterial pressure target was 80 mm Hg or greater; before and for 2 days after surgery, renin– angiotensin–aldosterone system inhibitors were withheld and the other long-term antihypertensive medications were administered only for systolic blood pressures 130 mm Hg or greater, following an algorithm. In the hypertension-avoidance strategy group, the intraoperative mean arterial pressure target was 60 mm Hg or greater; all antihypertensive medications were continued before and after surgery.
Measurements:
The primary outcome was a composite of vascular death and nonfatal myocardial injury after noncar- diac surgery, stroke, and cardiac arrest at 30 days. Outcome adjudicators were masked to treatment assignment.
Results:
The primary outcome occurred in 520 of 3742 patients (13.9%) in the hypotension-avoidance group and in 524 of 3748 patients (14.0%) in the hypertension-avoidance group (hazard ratio, 0.99 [95% CI, 0.88 to 1.12]; P = 0.92). Results were con- sistent for patients who used 1 or more than 1 antihypertensive medication in the long term.
Limitation:
Adherence to the assigned strategies was sub- optimal; however, results were consistent across different ad- herence levels.
Conclusion:
In patients having noncardiac surgery, our hypotension-avoidance and hypertension-avoidance strat- egies resulted in a similar incidence of major vascular complications.
Primary Funding Source
Canadian Institutes of Health
Research, National Health and Medical Research Council (Australia), and Research Grant Council of Hong Kong.