TY - JOUR

T1 - Hypotension-Avoidance Versus Hypertension-Avoidance Strategies in Noncardiac Surgery: An International Randomized Controlled Trial

AU - POISE-3 Trial Investigators and Study Groups

AU - Marcucci, Maura

AU - Painter, Thomas W

AU - Conen, David

AU - Lomivorotov, Vladimir

AU - Sessler, Daniel I

AU - Chan, Matthew T V

AU - Borges, Flavia K

AU - Leslie, Kate

AU - Duceppe, Emmanuelle

AU - Martínez-Zapata, María José

AU - Wang, Chew Yin

AU - Xavier, Denis

AU - Ofori, Sandra N

AU - Wang, Michael Ke

AU - Efremov, Sergey

AU - Landoni, Giovanni

AU - Kleinlugtenbelt, Ydo V

AU - Szczeklik, Wojciech

AU - Schmartz, Denis

AU - Garg, Amit X

AU - Short, Timothy G

AU - Wittmann, Maria

AU - Meyhoff, Christian S

AU - Amir, Mohammed

AU - Torres, David

AU - Patel, Ameen

AU - Ruetzler, Kurt

AU - Parlow, Joel L

AU - Tandon, Vikas

AU - Fleischmann, Edith

AU - Polanczyk, Carisi A

AU - Lamy, Andre

AU - Jayaram, Raja

AU - Astrakov, Sergey V

AU - Wu, William Ka Kei

AU - Cheong, Chao Chia

AU - Ayad, Sabry

AU - Kirov, Mikhail

AU - de Nadal, Miriam

AU - Likhvantsev, Valery V

AU - Paniagua, Pilar

AU - Aguado, Hector J

AU - Maheshwari, Kamal

AU - Whitlock, Richard P

AU - McGillion, Michael H

AU - Vincent, Jessica

AU - Copland, Ingrid

AU - Balasubramanian, Kumar

AU - Biccard, Bruce M

AU - Srinathan, Sadeesh

N1 - Financial Support: By Canadian Institutes of Health Research Foundation Grant awarded to Dr. Devereaux (FDN-143302); National Health and Medical Research Council, Funding Schemes, NHMRC Project Grant 1162362; and General Research Fund 14104419, Research Grant Council, Hong Kong SAR, China. POISE-3 also received financial support from the Population Health Research Institute and the Hamilton Health Science Research Institute, and an investigator-initiated study grant from Roche Diagnostics International. Primary Funding Source: Canadian Institutes of Health Research, National Health and Medical Research Council (Australia), and Research Grant Council of Hong Kong.

PY - 2023/5

Y1 - 2023/5

N2 - 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.

AB - 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.

UR - https://www.scopus.com/record/display.uri?eid=2-s2.0-85159734603&origin=inward&txGid=88ba6d9ac08a785de8a9fee357c685a9

UR - http://www.ncbi.nlm.nih.gov/pubmed/37094336

UR - https://www.mendeley.com/catalogue/977a5f72-6386-39ea-ab2c-ef7942539532/

U2 - 10.7326/M22-3157

DO - 10.7326/M22-3157

M3 - Article

C2 - 37094336

VL - 176

SP - 605

EP - 614

JO - Annals of internal medicine

JF - Annals of internal medicine

SN - 0003-4819

IS - 5

ER -