Publications of the Week: Hypertension and hypotension avoidance in noncardiac surgery



Marcucci M, Painter TW, Conen D, et al; POISE-3 Trial Investigators and Study Groups. Hypotension-Avoidance Versus Hypertension-Avoidance Strategies in Noncardiac Surgery: An International Randomized Controlled Trial. Ann Intern Med. 2023 May;176(5):605-614. doi: 10.7326/M22-3157. Epub 2023 Apr 25. PMID: 37094336.

A McMaster Perspective interview with a POISE-3 trial author will be available soon.

Background: In patients having noncardiac surgery there is uncertainty regarding how to manage antihypertensive drug therapy before and after surgery and about the optimal intraoperative blood pressure to target.

Methods: The objective of this randomized trial, conducted as part of the POISE-3 (PeriOperative Ischemic Evaluation-3) study, was to compare the effects of a hypotension-avoidance strategy versus a hypertension-avoidance strategy on vascular complications after noncardiac surgery. This was a randomized open-label trial done in 7490 patients who had ≥1 major vascular risk factor, were receiving ≥1 antihypertensive drug, and were having elective noncardiac surgery.

The hypotension-avoidance strategy involved (1) a target intraoperative mean arterial blood pressure (MABP) ≥80 mm Hg; (2) withholding angiotensin converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), or direct renin inhibitors starting on the evening before surgery and for 2 days after surgery; and (3) administering other antihypertensive drugs only for a systolic blood pressure (SBP) ≥130 mm Hg on the basis of an algorithm.

The hypertension-avoidance strategy involved (1) a target intraoperative MABP ≥60 mm Hg and (2) continuing all antihypertensive drugs before and after surgery.

The primary study outcome was a composite of vascular death and nonfatal myocardial injury after noncardiac surgery, stroke, and cardiac arrest at 30 days.

Results: The primary outcome occurred in 13.9% of patients (520/3742) in the hypotension-avoidance group and in 14.0% of patients (524/3748) in the hypertension-avoidance group (hazard ratio [HR], 0.99; 95% CI, 0.88-1.12). This finding was observed irrespective of whether patients were taking only 1 or >1 antihypertensive drug and irrespective of the drug adherence level.

Conclusions: The authors concluded that in patients having noncardiac surgery both a hypotension-avoidance strategy and a hypertension-avoidance strategy resulted in a similar incidence of major vascular complications.

McMaster editors’ commentary: In this trial the hypotension-avoidance strategy was associated with a decrease in the incidence of intraoperative hypotension (19.1% vs 24.9%) but no difference in postoperative hypotension or in adverse events. A key message from the investigators was that perioperative ACEI/ARB management should be individualized. For example, in patients who have a propensity for hypertensive exacerbations, ACEIs/ARBs can be continued perioperatively, whereas such treatment can be withheld in those with a tendency for lower blood pressure readings.

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