Scientific publications
Hypotension-Avoidance Versus Hypertension-Avoidance Strategies in Noncardiac Surgery : An International Randomized Controlled Trial
Maura Marcucci 1 , Thomas W Painter 2 , David Conen 1 , Vladimir Lomivorotov 3 , Daniel I Sessler 4 , Matthew T V Chan 5 , Flavia K Borges 1 , Kate Leslie 6 , Emmanuelle Duceppe 7 , María José Martínez-Zapata 8 , Chew Yin Wang 9 , Denis Xavier 10 , Sandra N Ofori 1 , Michael Ke Wang 1 , Sergey Efremov 11 , Giovanni Landoni 12 , Ydo V Kleinlugtenbelt 13 , Wojciech Szczeklik 14 , Denis Schmartz 15 , Amit X Garg 16 , Timothy G Short 17 , Maria Wittmann 18 , Christian S Meyhoff 19 , Mohammed Amir 20 , David Torres 21 , Ameen Patel 22 , Kurt Ruetzler 4 , Joel L Parlow 23 , Vikas Tandon 22 , Edith Fleischmann 24 , Carisi A Polanczyk 25 , Andre Lamy 1 , Raja Jayaram 26 , Sergey V Astrakov 27 , William Ka Kei Wu 5 , Chao Chia Cheong 9 , Sabry Ayad 4 , Mikhail Kirov 28 , Miriam de Nadal 29 , Valery V Likhvantsev 30 , Pilar Paniagua 31 , Hector J Aguado 32 , Kamal Maheshwari 4 , Richard P Whitlock 1 , Michael H McGillion 1 , Jessica Vincent 1 , Ingrid Copland 1 , Kumar Balasubramanian 1 , Bruce M Biccard 33 , Sadeesh Srinathan 34 , Samandar Ismoilov 3 , Shirley Pettit 1 , David Stillo 1 , Andrea Kurz 4 , Emilie P Belley-Côté 1 , Jessica Spence 1 , William F McIntyre 1 , Shrikant I Bangdiwala 1 , Gordon Guyatt 35 , Salim Yusuf 1 , P J Devereaux 1 ; POISE-3 Trial Investigators and Study Groups
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.
CITATION Ann Intern Med. 2023 May;176(5):605-614. doi: 10.7326/M22-3157. Epub 2023 Apr 25.
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