Hypotensive-avoidance strategies not associated with decrease in postoperative hypotension or adverse outcomes

Abstract: https://www.acpjournals.org/doi/10.7326/M22-3157

Editorial: https://www.acpjournals.org/doi/10.7326/M23-0745

URL goes live when the embargo lifts

A randomized trial of more than 7,000 people found that hypotension-avoidance strategies were not associated with a decrease in postoperative hypotension or adverse outcomes compared with hypertension-avoidance strategies. The findings are published in Annals of Internal Medicine.

Hypotension is common during and after noncardiac surgery. It is also associated with an increased risk for death and cardiovascular complications at 30 days after noncardiac surgery. Similarly, postoperative hypertension is associated with vascular complications after noncardiac surgery. Half of adults having major noncardiac surgery have a history of hypertension, and most use antihypertension medication. Uncertainty remains about what intraoperative blood pressure to target and how to manage long-term antihypertensive medications perioperatively.

Researchers from Population Health Research Institute conducted a partial factorial randomized trial of 7,490 people using two perioperative blood pressure management strategies. Patients using the hypotension-avoidance strategy did not take angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin-receptor blockers (ARBs) from the night before surgery through postoperative day 2, resuming them 3 days after surgery. Patients using the hypertension-avoidance strategy received all their usual antihypertensives preoperatively, including on the morning of surgery, and postoperatively. The authors found that fewer patients using the hypotensive-avoidance strategy experienced clinically significant hypotension compared with patients using the hypertensive-avoidance strategy. However, there was no difference between strategies related to vascular death and nonfatal myocardial injury, stroke, or cardiac arrest. According to the authors, further research is needed to identify and evaluate perioperative interventions that can modify hemodynamics to an extent and in the direction that will lead to a favorable effect on major clinical outcomes.

An accompanying editorial from authors at the University of Nebraska Medical Center and Cleveland Clinic Lerner College of Medicine highlights that the decision about whether to hold selected antihypertensive medications for surgery remains a nuanced, individualized decision. They emphasize that the degree and possibly the duration of hypotension experienced by patients in this study may have been inadequate to affect the outcomes that were studied. The authors also call for future studies to examine both intraoperative and postoperative management strategies, identify other patient risk factors for poor outcomes, and ensure the clarity of surrogate versus patient-relevant clinical outcomes.

Media contacts: For an embargoed PDF, please contact Angela Collom at [email protected]. To speak with corresponding author P.J. Devereaux, MD, PhD, please email [email protected].