No difference in major vascular complications with different blood pressure strategies after noncardiac surgery (POISE-3)

Reference

Marcucci M, Painter TW, Conen D, et al, for the POISE-3 Trial Investigators and Study Groups. Hypotension-avoidance versus hypertension-avoidance strategies in noncardiac surgery. Ann Intern Med 2023;176(5):605-614.

Synopsis

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.