Background: Perioperative hemodynamic abnormalities have been associated with neurocognitive outcomes after noncardiac surgery. Objective: To compare the effects of perioperative hypotension-avoidance versus hypertension-avoidance strategies on delirium and 1-year cognitive decline after noncardiac surgery. Design: Randomized controlled trial. (ClinicalTrials. gov: NCT03505723) Setting: 54 centers, 19 countries. Participants: 2603 high-vascular-risk patients undergoing noncardiac surgery, receiving 1 or more chronic antihypertensive medications (mean age, 70 years). Intervention: In the hypotension-avoidance strategy, the intraoperative mean arterial pressure (MAP) target was 80 mm Hg or greater; before and for 2 days after surgery, renin-angiotensin-aldosterone system inhibitors were withheld, and other chronic antihypertensive medications were administered for systolic blood pressures of 130 mm Hg or greater following an algorithm. In the hypertension-avoidance strategy, the intraoperative MAP target was 60 mm Hg or greater; all chronic antihypertensive medications were continued perioperatively. Measurements: Delirium on postoperative day 1 to 3 (primary outcome); decline of 2 points or more at the Montreal Cognitive Assessment (MoCA) 1 year after surgery compared with baseline (secondary outcome). Results: 95 of 1310 patients (7.3%) in the hypotension-avoidance and 90 of 1293 patients (7.0%) in the hypertension-avoidance group had delirium (relative risk [RR], 1.04 [95% CI, 0.79 to 1.38]). Among 701 patients who completed 1-year MoCA (full or telephone version), 129 of 347 (37.2%) in the hypotension-avoidance and 117 of 354 (33.1%) in the hypertension-avoidance group had a decline of 2 or more points (RR, 1.13 [CI, 0.92 to 1.38]). Nineteen percent in the hypotension-avoidance and 27% in the hypertension-avoidance strategy had hypotension requiring an intervention (RR, 0.63 [CI, 0.52 to 0.76]), mostly intraoperatively; only 5%, in both groups, had hypotension postoperatively. Limitation: The COVID-19 pandemic challenged site participation in the substudy; although large, the sample size was lower than expected. Conclusion: There was no evidence of a difference in neurocognitive outcomes between the hypotension-avoidance and hypertension-avoidance strategies.
Effects of a Hypotension-Avoidance Versus a Hypertension-Avoidance Strategy on Neurocognitive Outcomes After Noncardiac Surgery / Marcucci, M.; Chan, M. T. V.; Painter, T. W.; Efremov, S.; Aguado, H. J.; Astrakov, S. V.; Kleinlugtenbelt, Y. V.; Patel, A.; Cata, J. P.; Amir, M.; Kirov, M.; Leslie, K.; Duceppe, E.; Borges, F. K.; De Nadal, M.; Tandon, V.; Landoni, G.; Likhvantsev, V. V.; Lomivorotov, V.; Sessler, D. I.; Martinez-Zapata, M. J.; Xavier, D.; Fleischmann, E.; Wang, C. Y.; Meyhoff, C. S.; Wittmann, M.; Torres, D.; Highton, D.; Jacka, M.; Vishwanath, B.; Zarnke, K.; Sidhu, R. S.; Oriani, G.; Ayad, S.; Minear, S.; Weaver, T. E.; Ruetzler, K.; Brusasco, C.; Parlow, J. L.; Maxwell, E.; Miller, S.; Mrkobrada, M.; Bhatt, K. S. C.; Rahate, P.; Kowark, A.; De Blasio, G.; Ofori, S. N.; Conen, D.; Srinathan, S.; Szczeklik, W.; Jayaram, R.; Ellerkmann, R. K.; Momeni, M.; Copland, I.; Vincent, J.; Balasubramanian, K.; Li, Z.; Wang, M. K.; Li, D.; Mcgillion, M. H.; Kurz, A.; Sharma, M.; Short, T. G.; Devereaux, P. J.. - In: ANNALS OF INTERNAL MEDICINE. - ISSN 0003-4819. - 178:7(2025), pp. 909-920. [10.7326/ANNALS-24-02841]
Effects of a Hypotension-Avoidance Versus a Hypertension-Avoidance Strategy on Neurocognitive Outcomes After Noncardiac Surgery
Landoni G.;
2025-01-01
Abstract
Background: Perioperative hemodynamic abnormalities have been associated with neurocognitive outcomes after noncardiac surgery. Objective: To compare the effects of perioperative hypotension-avoidance versus hypertension-avoidance strategies on delirium and 1-year cognitive decline after noncardiac surgery. Design: Randomized controlled trial. (ClinicalTrials. gov: NCT03505723) Setting: 54 centers, 19 countries. Participants: 2603 high-vascular-risk patients undergoing noncardiac surgery, receiving 1 or more chronic antihypertensive medications (mean age, 70 years). Intervention: In the hypotension-avoidance strategy, the intraoperative mean arterial pressure (MAP) target was 80 mm Hg or greater; before and for 2 days after surgery, renin-angiotensin-aldosterone system inhibitors were withheld, and other chronic antihypertensive medications were administered for systolic blood pressures of 130 mm Hg or greater following an algorithm. In the hypertension-avoidance strategy, the intraoperative MAP target was 60 mm Hg or greater; all chronic antihypertensive medications were continued perioperatively. Measurements: Delirium on postoperative day 1 to 3 (primary outcome); decline of 2 points or more at the Montreal Cognitive Assessment (MoCA) 1 year after surgery compared with baseline (secondary outcome). Results: 95 of 1310 patients (7.3%) in the hypotension-avoidance and 90 of 1293 patients (7.0%) in the hypertension-avoidance group had delirium (relative risk [RR], 1.04 [95% CI, 0.79 to 1.38]). Among 701 patients who completed 1-year MoCA (full or telephone version), 129 of 347 (37.2%) in the hypotension-avoidance and 117 of 354 (33.1%) in the hypertension-avoidance group had a decline of 2 or more points (RR, 1.13 [CI, 0.92 to 1.38]). Nineteen percent in the hypotension-avoidance and 27% in the hypertension-avoidance strategy had hypotension requiring an intervention (RR, 0.63 [CI, 0.52 to 0.76]), mostly intraoperatively; only 5%, in both groups, had hypotension postoperatively. Limitation: The COVID-19 pandemic challenged site participation in the substudy; although large, the sample size was lower than expected. Conclusion: There was no evidence of a difference in neurocognitive outcomes between the hypotension-avoidance and hypertension-avoidance strategies.I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.
