Is hypotension avoidance better than hypertension avoidance in noncardiac surgery?

The incidence of major vascular complications among patients who underwent noncardiac surgery is similar between hypotension- and hypertension-avoidance strategies, reports a study.

A partial factorial randomized trial was conducted in 7,490 patients having noncardiac surgery who were at risk for vascular complications and receiving one or more long-term antihypertensive medications from 110 hospitals in 22 countries. Two perioperative blood pressure (BP) management (hypotension-avoidance vs hypertension-avoidance) strategies and tranexamic acid versus placebo were compared.

In the hypotension-avoidance strategy arm, the intraoperative mean arterial pressure target was ≥80 mm Hg. The investigators withheld the renin–angiotensin–aldosterone system inhibitors before and 2 days after surgery, and administered the other long-term antihypertensive medications only for systolic BP ≥130 mm Hg, following an algorithm.

In the hypertension-avoidance strategy arm, the intraoperative mean arterial pressure target was ≥60 mm Hg. Antihypertensive medications were maintained before and after surgery.

The composite of vascular death and nonfatal myocardial injury after noncardiac surgery, stroke, and cardiac arrest at 30 days (primary outcome) occurred in 520 of 3,742 patients (13.9 percent) in the hypotension-avoidance group and in 524 of 3,748 (14.0 percent) in the hypertension-avoidance group (hazard ratio, 0.99, 95 percent confidence interval, 0.88‒1.12; p=0.92).

These results persisted in patients who used one or more antihypertensive medications in the long term.

As a limitation, adherence to the assigned strategies was unsatisfactory, but the results were consistent across various adherence levels.