No difference in outcomes after non-cardiac surgery with hypotension- versus hypertension-avoidance

1. In this randomized controlled trial, no difference in vascular complications following non-cardiac surgery was found with hypotension- versus hypertension-avoidance strategies.

2. While the incidence of intraoperative hypotension was higher in the hypertension-avoidance group, there were no differences between groups in postoperative hypotension.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Perioperative hypotension and hypertension are associated with increased vascular complications 30 days after non-cardiac surgery. There is a paucity of data on postsurgical outcomes with hypotension- and hypertension-avoidance strategies. In this unblinded randomized trial, patients undergoing non-cardiac surgery with vascular risk factors were managed perioperatively with hypotension- and hypertension-avoidance strategies. For the primary outcome, there was no significant difference in the incidence of a composite of vascular death and nonfatal myocardial injury after non-cardiac surgery (MINS), stroke, and cardiac arrest 30 days after randomization. Subgroup analyses with patients on long-term therapy with angiotensin-converting enzyme inhibitors (ACEi) compared to angiotensin receptor blockers (ARB) and different preoperative systolic blood pressure or N-terminal pro-B-type natriuretic peptide values showed similar results as the overall analysis. In summary, the incidence of clinically significant hypotension was lower in the hypotension-avoidance group compared to the hypertension-avoidance group. As a limitation, treatment was unblinded, and there was relatively low adherence to perioperative use of long-term antihypertensive medications.

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In-Depth [randomized controlled trial]: In this unblinded randomized trial, patients over the age of 45 with vascular risk factors undergoing non-cardiac surgery were randomized into hypotension-avoidance (n=3,742) and hypertension-avoidance (n=3,748) groups. In the hypotension-avoidance group, intraoperative mean arterial pressure and perioperative systolic blood pressure were maintained at a target of greater than 80 mm Hg and 130 mm Hg, respectively. In the hypertension-avoidance group, intraoperative mean arterial pressure was maintained at 60 mm Hg or greater, and patients were allowed to receive all their long-term antihypertensive medications. For the primary outcome, there were no significant differences in the incidence of combined vascular death, nonfatal MINS, stroke, and cardiac arrest at 30 days after randomization (13.9% and 14.0% in the hypotension-avoidance and hypertension-avoidance groups, respectively; absolute risk difference of 0.08 percentage points). According to allocated strategies, the daily mean adherence to anti-hypertensive medications ranged between 68.3% and 74.6% in the hypotension-avoidance group and between 56.7% and 70.4% in the hypertension-avoidance group. Clinically significant hypotension occurred in fewer patients in the hypotension-avoidance group than in the hypertension-avoidance group (odds ratio, 0.74; 95% confidence interval, 0.66 to 0.82). This study showed no difference in the effects of blood pressure management on major vascular complications in patients undergoing non-cardiac surgery.

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