Hypotension- and hypertension-avoidance strategies may yield similar neurocognitive outcomes following noncardiac surgery

1. In this randomized controlled trial, hypotension- and hypertension-avoidance strategies yielded similar post-operative delirium frequency and severity following non-cardiac surgery.

2. The two strategies also demonstrated similar rates of cognitive decline at 1 year following noncardiac surgery.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Delirium is an acute neuropsychiatric syndrome characterized by fluctuating disturbances in awareness, attention, cognitive function, and psychomotor activity. Up to one-fifth of older patients undergoing non-cardiac surgery develop post-operative delirium, and those with cognitive impairment or increased comorbidities are at particularly high risk. Post-operative delirium is associated with poor outcomes, including increased morbidity and mortality, long-term cognitive impairment, and incident dementia. Substantial cognitive decline has been reported in as high as one-third of elderly patients 1 year after major non-cardiac surgery. Prior observational studies have reported that peri-operative hypotension and hypertension may increase the risk of post-operative delirium and cognitive decline, although results have been inconsistent. No randomized controlled trials to date have evaluated the effect of peri-operative continuation and discontinuation of anti-hypertensive agents on neurocognition. Hence, this randomized controlled trial investigated the effects of perioperative hypotension-avoidance versus hypertension-avoidance strategies on neurocognitive outcomes. Overall, it found that hypotension- and hypertension-avoidance strategies yielded no significant differences in post-operative delirium frequency or severity following non-cardiac surgery. In addition, both strategies demonstrated similar rates of cognitive decline at 1 year following non-cardiac surgery. The study was limited by the COVID-19 pandemic, which resulted in a smaller sample size than expected. Nonetheless, these results suggested that hypotension- and hypertension-avoidance strategies had no significant effect on post-operative neurocognitive outcomes.

Click to read the study in AIM

Relevant Reading: Estimates of geriatric delirium frequency in noncardiac surgeries and its evaluation across the years: a systematic review and meta-analysis

In-Depth [randomized controlled trial]: cogPOISE-3, a substudy of the POISE-3 (PeriOperative Ischemic Evaluation) trial, was an international randomized controlled trial which investigated peri-operative hypotension-avoidance versus hypertension-avoidance strategies on delirium and 1-year cognitive decline following non-cardiac surgery. Participants were 45 years of age or older with a history of vascular disease taking at least 1 anti-hypertensive agent before surgery. A total of 2834 patients were randomized in a 1:1 ratio to either the perioperative hypotension-avoidance or hypertension-avoidance strategies. In the hypotension-avoidance arm, the intraoperative mean arterial pressure (MAP) target was 80 mmHg or greater and all renin–angiotensin–aldosterone system (RAAS) inhibitors were withheld before and for 2 days after surgery. All other anti-hypertensive agents were administered for systolic blood pressures of 130 mmHg or greater. In the hypertension-avoidance arm, the intraoperative MAP target was 60 mmHg or greater and all chronic anti-hypertensive agents were continued peri-operatively. The primary outcome was delirium during the first 3 post-operative days, assessed using 3D-CAM (3-Minute Diagnostic Confusion Assessment Method). The main secondary outcome was a decline of 2 points or more on the MoCA (Montreal Cognitive Assessment) from baseline. Overall, 95 of 1,310 patients (7.3%) in the hypotension-avoidance group and 90 of 1,293 patients (7.0%) in the hypertension-avoidance group had delirium (relative risk [RR], 1.04; 95% confidence interval [CI], 0.79 to 1.38; P = 0.77), with 17.7% versus 18.0% of patients in the respective groups scoring 2 or more points on the 3D-CAM severity assessment (RR, 1.00 [95% CI, 0.96 to 1.04]; P = 0.86). Of the 701 patients who completed 1-year MoCA, a decrease of 2 or more points occurred in 129 of 347 (37.2%) in the hypotension-avoidance group and 117 of 354 (33.1%) in the hypertension-avoidance group (RR, 1.20 [CI, 0.88 to 1.64]; P = 0.25). In summary, this trial demonstrated no difference in neurocognitive outcomes between hypotension-avoidance and hypertension-avoidance strategies in individuals undergoing non-cardiac surgery.

Image: PD

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