Publications
Hypotension-Avoidance Versus Hypertension-Avoidance Strategies in Noncardiac Surgery : An International Randomized Controlled Trial
Maura Marcucci 1, Thomas W Painter 2, David Conen 1, Vladimir Lomivorotov 3, Daniel I Sessler 4, Matthew T V Chan 5, Flavia K Borges 1, Kate Leslie 6, Emmanuelle Duceppe 7, María José Martínez-Zapata 8, Chew Yin Wang 9, Denis Xavier 10, Sandra N Ofori 1, Michael Ke Wang 1, Sergey Efremov 11, Giovanni Landoni 12, Ydo V Kleinlugtenbelt 13, Wojciech Szczeklik 14, Denis Schmartz 15, Amit X Garg 16, Timothy G Short 17, Maria Wittmann 18, Christian S Meyhoff 19, Mohammed Amir 20, David Torres 21, Ameen Patel 22, Kurt Ruetzler 4, Joel L Parlow 23, Vikas Tandon 22, Edith Fleischmann 24, Carisi A Polanczyk 25, Andre Lamy 1, Raja Jayaram 26, Sergey V Astrakov 27, William Ka Kei Wu 5, Chao Chia Cheong 9, Sabry Ayad 4, Mikhail Kirov 28, Miriam de Nadal 29, Valery V Likhvantsev 30, Pilar Paniagua 31, Hector J Aguado 32, Kamal Maheshwari 4, Richard P Whitlock 1, Michael H McGillion 1, Jessica Vincent 1, Ingrid Copland 1, Kumar Balasubramanian 1, Bruce M Biccard 33, Sadeesh Srinathan 34, Samandar Ismoilov 3, Shirley Pettit 1, David Stillo 1, Andrea Kurz 4, Emilie P Belley-Côté 1, Jessica Spence 1, William F McIntyre 1, Shrikant I Bangdiwala 1, Gordon Guyatt 35, Salim Yusuf 1, P J Devereaux 1; POISE-3 Trial Investigators and Study Groups Abstract
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.
