TY - JOUR

T1 - Hypotension-Avoidance Versus Hypertension-Avoidance Strategies in Noncardiac Surgery

T2 - An International Randomized Controlled Trial

AU - Marcucci, Maura

AU - Painter, Thomas W.

AU - Conen, David

AU - Lomivorotov, Vladimir

AU - Sessler, Daniel I.

AU - Chan, Matthew T.V.

AU - Borges, Flavia K.

AU - Leslie, Kate

AU - Duceppe, Emmanuelle

AU - Martínez-Zapata, María José

AU - Wang, Chew Yin

AU - Xavier, Denis

AU - Ofori, Sandra N.

AU - Wang, Michael Ke

AU - Efremov, Sergey

AU - Landoni, Giovanni

AU - Kleinlugtenbelt, Ydo V.

AU - Szczeklik, Wojciech

AU - Schmartz, Denis

AU - Garg, Amit X.

AU - Short, Timothy G.

AU - Wittmann, Maria

AU - Meyhoff, Christian S.

AU - Amir, Mohammed

AU - Torres, David

AU - Patel, Ameen

AU - Ruetzler, Kurt

AU - Parlow, Joel L.

AU - Tandon, Vikas

AU - Fleischmann, Edith

AU - Polanczyk, Carisi A.

AU - Lamy, Andre

AU - Jayaram, Raja

AU - Astrakov, Sergey V.

AU - Wu, William Ka Kei

AU - Cheong, Chao Chia

AU - Ayad, Sabry

AU - Kirov, Mikhail

AU - de Nadal, Miriam

AU - Likhvantsev, Valery V.

AU - Paniagua, Pilar

AU - Aguado, Hector J.

AU - Maheshwari, Kamal

AU - Whitlock, Richard P.

AU - McGillion, Michael H.

AU - Vincent, Jessica

AU - Copland, Ingrid

AU - Balasubramanian, Kumar

AU - Biccard, Bruce M.

AU - Srinathan, Sadeesh

AU - POISE-3 Trial Investigators and Study Groups

N1 - Funding Information: Financial Support: By Canadian Institutes of Health Research Foundation Grant awarded to Dr. Devereaux (FDN-143302); National Health and Medical Research Council, Funding Schemes, NHMRC Project Grant 1162362; and General Research Fund 14104419, Research Grant Council, Hong Kong SAR, China. POISE-3 also received financial support from the Population Health Research Institute and the Hamilton Health Science Research Institute, and an investigator-initiated study grant from Roche Diagnostics International. Funding Information: Primary Funding Source: Canadian Institutes of Health Research, National Health and Medical Research Council (Australia), and Research Grant Council of Hong Kong. Publisher Copyright: © 2023 American College of Physicians.

PY - 2023

Y1 - 2023

N2 - 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 complications after noncardiac surgery. Design: Partial factorial randomized trial of 2 perioperative blood pressure management strategies (reported here) and tranexamic 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 noncardiac 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 consistent for patients who used 1 or more than 1 antihypertensive medication in the long term. Limitation: Adherence to the assigned strategies was suboptimal; however, results were consistent across different adherence levels. Conclusion: In patients having noncardiac surgery, our hypotension-avoidance and hypertension-avoidance strategies resulted in a similar incidence of major vascular complications.

AB - 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 complications after noncardiac surgery. Design: Partial factorial randomized trial of 2 perioperative blood pressure management strategies (reported here) and tranexamic 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 noncardiac 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 consistent for patients who used 1 or more than 1 antihypertensive medication in the long term. Limitation: Adherence to the assigned strategies was suboptimal; however, results were consistent across different adherence levels. Conclusion: In patients having noncardiac surgery, our hypotension-avoidance and hypertension-avoidance strategies resulted in a similar incidence of major vascular complications.

U2 - 10.7326/M22-3157

DO - 10.7326/M22-3157

M3 - Journal article

C2 - 37094336

AN - SCOPUS:85159734603

VL - 176

SP - 605

EP - 614

JO - Annals of Internal Medicine

JF - Annals of Internal Medicine

SN - 0003-4819

IS - 5

ER -