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.
Hypotension-Avoidance Versus Hypertension-Avoidance Strategies in Noncardiac Surgery / Marcucci, M.; Painter, T. W.; Conen, D.; Lomivorotov, V.; Sessler, D. I.; Chan, M. T. V.; Borges, F. K.; Leslie, K.; Duceppe, E.; Jose' Martinez-Zapata, M.; Yin Wang, C.; Xavier, D.; Ofori, S. N.; Ke Wang, M.; Efremov, S.; Landoni, G.; Kleinlugtenbelt, Y. V.; Szczeklik, W.; Schmartz, D.; Garg, A. X.; Short, T. G.; Wittmann, M.; Meyhoff, C. S.; Amir, M.; Torres, D.; Patel, A.; Ruetzler, K.; Parlow, J.; Tandon, V.; Fleischmann, E.; Polanczyk, C. A.; Lamy, A.; Jayaram, R.; Astrakov, S. V.; Ka Kei Wu, W.; Chia Cheong, C.; Ayad, S.; Kirov, M.; De Nadal, M.; Likhvantsev, V. V.; Paniagua, P.; Aguado, H. J.; Maheshwari, K.; Whitlock, R. P.; Mcgillion, M. H.; Vincent, J.; Copland, I.; Kumar, Balasubramanian; Biccard, B. M.; Srinathan, S.; Ismoilov, S.; Pettit, S.; Stillo, D.; Kurz, A.; Belley-Cote, E. P.; Spence, J.; Mcintyre, W. F.; Bangdiwala, S. I.; Guyatt, G.; Yusuf, S.; Devereaux, P. J.. - In: ANNALS OF INTERNAL MEDICINE. - ISSN 0003-4819. - 176:11(2023), pp. 605-615. [10.7326/L23-0324]
Hypotension-Avoidance Versus Hypertension-Avoidance Strategies in Noncardiac Surgery
Landoni G.;
2023-01-01
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.I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.
