For patients undergoing noncardiac surgery, do blood pressure management strategies for hypotension avoidance or hypertension avoidance decrease the risk of major vascular complications?
This large, randomized trial showed no difference in outcomes when comparing 2 different blood pressure management strategies — hypotension avoidance and hypertension avoidance — in the perioperative period. Adherence to the strategies, however, was suboptimal. Additionally, there was no difference between the 2 groups in clinically important hypotension during the postoperative period, despite the different strategies.
Randomized controlled trial (nonblinded)
Inpatient (any location)
For this international study, the investigators enrolled patients (45 years or older) who were undergoing inpatient noncardiac surgery, had either a history of or risk factors for vascular disease, and were taking one or more antihypertensive medications. Patients were randomized, using concealed allocation, to receive a hypotension-avoidance strategy or a hypertension-avoidance strategy. In the hypotension-avoidance group (n = 3742), the following steps were used: (1) discontinuing renin-angiotensin-aldosterone system inhibitors (eg, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers) prior to surgery, (2) targeting an intraoperative mean arterial pressure (MAP) of 80 mmHg or higher, and (3) administering other long-term antihypertensives during the postoperative period only for a systolic blood pressure of 130 mmHg or higher. In the hypertension-avoidance group (n = 3748), patients continued all long-term antihypertensive medications both before and after surgery, and intraoperative MAP was targeted at 60 mmHg or higher. Baseline characteristics were similar in the 2 groups: 44% of participants in each group were women (mean age = 70 years). Adherence to the study strategy ranged from approximately 60% to 70%. For the primary outcome —a composite of vascular death, nonfatal myocardial injury, stroke, and cardiac death at 30 days — there was no significant difference between the 2 groups (both with a rate of 14%). Similarly, there were no differences in any individual secondary outcomes. Of note, although intraoperative MAPs were significantly different between the 2 groups, there was little difference in systolic blood pressure or heart rate outside the operating room, suggesting that the lack of effect may be due to a lack of clinically important changes in hemodynamics when comparing patients who received different strategies.
Nita Shrikant Kulkarni, MD
Assistant Professor in Hospital Medicine