Bibliographic Details
| Title: |
Hypotension-Avoidance Versus Hypertension-Avoidance Strategies in Noncardiac Surgery: An International Randomized Controlled Trial. |
| Authors: |
Marcucci, Maura, Painter, Thomas W., Conen, David, Lomivorotov, Vladimir, Sessler, Daniel I., Chan, Matthew T.V., Borges, Flavia K., Leslie, Kate, Duceppe, Emmanuelle, Martínez-Zapata, María José, Wang, Chew Yin, Xavier, Denis, Ofori, Sandra N., Wang, Michael Ke, Efremov, Sergey, Landoni, Giovanni, Kleinlugtenbelt, Ydo V., Szczeklik, Wojciech, Schmartz, Denis, Garg, Amit X. |
| Source: |
Annals of Internal Medicine; May2023, Vol. 176 Issue 5, p605-614, 11p, 1 Diagram, 3 Charts, 1 Graph |
| Subject Terms: |
VASCULAR surgery, RANDOMIZED controlled trials, SURGICAL complications, SYSTOLIC blood pressure, ANTIHYPERTENSIVE agents, MEDICAL research |
| Geographic Terms: |
HONG Kong (China) |
| Company/Entity: |
MEDICAL Research Council (Great Britain) |
| Abstract: |
Uncertainty exists around management of long-term antihypertensive medications around the time of noncardiac surgery and intraoperative blood pressures to target. This trial assigned patients to hypotension-avoidance versus hypertension-avoidance strategies in the preoperative setting and assessed differences in vascular death, nonfatal myocardial injury after noncardiac surgery, stroke, and cardiac arrest. Visual Abstract. Hypotension-Avoidance Versus Hypertension-Avoidance Strategies in Noncardiac Surgery: Uncertainty exists around management of long-term antihypertensive medications around the time of noncardiac surgery and intraoperative blood pressures to target. This trial assigned patients to hypotension-avoidance versus hypertension-avoidance strategies in the preoperative setting and assessed differences in vascular death, nonfatal myocardial injury after noncardiac surgery, stroke, and cardiac arrest. 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. [ABSTRACT FROM AUTHOR] |
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| Database: |
Complementary Index |
