Hypotension-Avoidance Versus Hypertension-Avoidance Strategies in Noncardiac Surgery : An International Randomized Controlled Trial

Marcucci M 1 , Painter TW 2 , Conen D 1 , Lomivorotov V 3 , Sessler DI 4 , Chan MTV 5 Show all authors , Borges FK 1 , Leslie K 6 , Duceppe E 7 , Martínez-Zapata MJ 8 , Wang CY 9 , Xavier D 10 , Ofori SN 1 , Wang MK 1 , Efremov S 11 , Landoni G 12 , Kleinlugtenbelt YV 13 , Szczeklik W 14 , Schmartz D 15 , Garg AX 16 , Short TG 17 , Wittmann M 18 , Meyhoff CS 19 , Amir M 20 , Torres D 21 , Patel A 22 , Ruetzler K 4 , Parlow JL 23 , Tandon V 22 , Fleischmann E 24 , Polanczyk CA 25 , Lamy A 1 , Jayaram R 26 , Astrakov SV 27 , Wu WKK 5 , Cheong CC 9 , Ayad S 4 , Kirov M 28 , de Nadal M 29 , Likhvantsev VV 30 , Paniagua P 31 , Aguado HJ 32 , Maheshwari K 4 , Whitlock RP 1 , McGillion MH 1 , Vincent J 1 , Copland I 1 , Balasubramanian K 1 , Biccard BM 33 , Srinathan S 34 , Ismoilov S 3 , Pettit S 1 , Stillo D 1 , Kurz A 4 , Belley-Côté EP 1 , Spence J 1 , McIntyre WF 1 , Bangdiwala SI 1 , Guyatt G 35 , Yusuf S 1 , Devereaux PJ 1 , POISE-3 Trial Investigators and Study Groups

Affiliations 

  • 1 Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
  • 2 Acute Care Medicine, University of Adelaide, Adelaide, South Australia, Australia (T.W.P.)
  • 3 Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Centre, Novosibirsk, Russia (V.L., S.I.)
  • 4 Anesthesiology Institute, Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio (D.I.S., K.R., S.A., K.M., A.K.)
  • 5 The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China (M.T.V.C., W.K.K.W.)
  • 6 Department of Critical Care Medicine, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia (K.L.)
  • 7 Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada (E.D.)
  • 8 Iberoamerican Cochrane Centre, Public Health and Clinical Epidemiology Service, IIB Sant Pau, CIBERESP, Barcelona, Spain (M.J.M.)
  • 9 Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia (C.Y.W., C.C.C.)
  • 10 St. John's Medical College, Bangalore, India (D.X.)
  • 11 Saint Petersburg State University Hospital, Saint Petersburg, Russia (S.E.)
  • 12 Department of Anesthesiology and Intensive Care, IRCCS San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy (G.L.)
  • 13 Department of Orthopedic and Trauma Surgery, Deventer Ziekenhuis, Deventer, the Netherlands (Y.V.K.)
  • 14 Centre for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland (W.S.)
  • 15 CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium (D.S.)
  • 16 Department of Medicine, Western University, London, Ontario, Canada (A.X.G.)
  • 17 Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand (T.G.S.)
  • 18 Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany (M.W.)
  • 19 Department of Anesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark (C.S.M.)
  • 20 Department of Surgery, Shifa International Hospital and Shifa Tameer-e-Millat University, Islamabad, Pakistan (M.A.)
  • 21 Departamento de Epidemiología y Estudios en Salud, Universidad de Los Andes, Santiago, Chile (D.T.)
  • 22 Department of Medicine, McMaster University, Hamilton, Ontario, Canada (A.P., V.T.)
  • 23 Department of Anesthesiology and Perioperative Medicine, Queen's University, and Kingston Health Sciences Centre, Kingston, Ontario, Canada (J.L.P.)
  • 24 Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria (E.F.)
  • 25 UFRGS, Hospital de Clínicas de Porto Alegre, National Institute for Health Technology Assessment, IATS; Hospital Moinhos de Vento, Porto Alegre, Brazil (C.A.P.)
  • 26 Department of Anaesthetics, Clinical Neurosciences, University of Oxford, Oxford University Hospitals NHS Trust, Oxford, United Kingdom (R.J.)
  • 27 Department of Anesthesiology, Novosibirsk State University, Novosibirsk, Russia (S.V.A.)
  • 28 Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russia (M.K.)
  • 29 Department of Anesthesiology and Intensive Care, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain (M. de N.)
  • 30 V. Negovsky Reanimatology Research Institute, Moscow, Russia (V.V.L.)
  • 31 Anesthesiology Department, Santa Creu i Sant Pau University Hospital, Barcelona, Spain (P.P.)
  • 32 Trauma & Orthopaedic Surgery Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain (H.J.A.)
  • 33 Department of Anesthesia and Perioperative Medicine, Groote Schuur Hospital, and University of Cape Town, Cape Town, South Africa (B.M.B.)
  • 34 Section of Thoracic Surgery, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada (S.S.)
  • 35 Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada (G.G.)
Ann Intern Med, 2023 May;176(5):605-614.
PMID: 37094336 DOI: 10.7326/M22-3157

Abstract

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.

PRIMARY FUNDING SOURCE: Canadian Institutes of Health Research, National Health and Medical Research Council (Australia), and Research Grant Council of Hong Kong.

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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