• Journal: Annals of Internal Medicine

• PMID: 37094336

• Type of study: Randomized controlled trial

• Objective

  • To compare a perioperative hypotension-avoidance strategy versus a hypertension-avoidance strategy

• Hypothesis

  • The hypotension-avoidance group would have a hazard ratio of 0.75 compared to the hypertension-avoidance group for the primary outcome

• Methods

  • Almost 7500 subjects

    • International

    • Multicenter

  • Inclusion criteria

    • > 45 years of age

    • Inpatient, noncardiac surgery

    • History of vascular disease or risk factors for vascular disease

    • Receiving 1 or more antihypertensive medications for at least 30 days in the 6 weeks before randomization 

  • Primary outcome

    • Composite outcome (at 30 days)

      • Vascular death

      • MINS

      • Stroke

      • Cardiac arrest

  • Groups

    • Hypertension-avoidance strategy

      • Preoperative management

        • Hold ACE-Is/ARBs

        • Administer other chronic antihypertensive meds based on algorithm

      • Intraoperative management

        • MAP goal ≥80 mm Hg 

      • Postoperative management (2 days postop)

        • Hold ACE-Is/ARBs 

        • Administer other chronic antihypertensive meds based on algorithm

    • Hypotension-avoidance strategy

      • Preoperative management

        • Take antihypertensive medications 

      • Intraoperative management 

        • MAP goal ≥60 mm Hg 

      • Postoperative management

        • Restart chronic antihypertensive medications postop

• Results

  • No significant difference in the primary outcome between the two groups

    • Hypertension-avoidance (14%) vs. hypotension-avoidance (13.9%)

    • Hazard ratio 0.99 (0.88 - 1.12)

  • No significant difference in individual components of the primary outcome

  • Minimal differences in BP achieved between the two groups

• Strengths

  • Randomized Controlled Trial

  • Large sample size, multicenter/multinational

  • Strong enrollment/follow-up

  • Pre-specified analyses

  • Intervention was both intra- and post-op

• Weaknesses

  • Less than 100% adherence to protocols

  • Intraoperative management of BP not standardized

  • Post-operative BP difficult to fully monitor

  • Minimal difference in BPs achieved between groups

  • Unblinded

• Key Point: A perioperative hypotension-avoidance strategy did not result in a lower incidence of major vascular complications compared to a hypertension-avoidance strategy

Ann Intern Med. 2023 May;176(5):605-614