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Hypotension-Avoidance Versus Hypertension-Avoidance Strategies in Noncardiac Surgery : An International Randomized Controlled Trial.
Marcucci, Maura; Painter, Thomas W; Conen, David; Lomivorotov, Vladimir; Sessler, Daniel I; Chan, Matthew T V; Borges, Flavia K; Leslie, Kate; Duceppe, Emmanuelle; Martínez-Zapata, María José; Wang, Chew Yin; Xavier, Denis; Ofori, Sandra N; Wang, Michael Ke; Efremov, Sergey; Landoni, Giovanni; Kleinlugtenbelt, Ydo V; Szczeklik, Wojciech; Schmartz, Denis; Garg, Amit X; Short, Timothy G; Wittmann, Maria; Meyhoff, Christian S; Amir, Mohammed; Torres, David; Patel, Ameen; Ruetzler, Kurt; Parlow, Joel L; Tandon, Vikas; Fleischmann, Edith; Polanczyk, Carisi A; Lamy, Andre; Jayaram, Raja; Astrakov, Sergey V; Wu, William Ka Kei; Cheong, Chao Chia; Ayad, Sabry; Kirov, Mikhail; de Nadal, Miriam; Likhvantsev, Valery V; Paniagua, Pilar; Aguado, Hector J; Maheshwari, Kamal; Whitlock, Richard P; McGillion, Michael H; Vincent, Jessica; Copland, Ingrid; Balasubramanian, Kumar; Biccard, Bruce M; Srinathan, Sadeesh.
Afiliación
  • Marcucci M; Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.).
  • Painter TW; Acute Care Medicine, University of Adelaide, Adelaide, South Australia, Australia (T.W.P.).
  • Conen D; Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.).
  • Lomivorotov V; Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Centre, Novosibirsk, Russia (V.L., S.I.).
  • Sessler DI; Anesthesiology Institute, Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio (D.I.S., K.R., S.A., K.M., A.K.).
  • Chan MTV; The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China (M.T.V.C., W.K.K.W.).
  • Borges FK; Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.).
  • Leslie K; Department of Critical Care Medicine, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia (K.L.).
  • Duceppe E; Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada (E.D.).
  • Martínez-Zapata MJ; Iberoamerican Cochrane Centre, Public Health and Clinical Epidemiology Service, IIB Sant Pau, CIBERESP, Barcelona, Spain (M.J.M.).
  • Wang CY; Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia (C.Y.W., C.C.C.).
  • Xavier D; St. John's Medical College, Bangalore, India (D.X.).
  • Ofori SN; Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.).
  • Wang MK; Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.).
  • Efremov S; Saint Petersburg State University Hospital, Saint Petersburg, Russia (S.E.).
  • Landoni G; Department of Anesthesiology and Intensive Care, IRCCS San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy (G.L.).
  • Kleinlugtenbelt YV; Department of Orthopedic and Trauma Surgery, Deventer Ziekenhuis, Deventer, the Netherlands (Y.V.K.).
  • Szczeklik W; Centre for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland (W.S.).
  • Schmartz D; CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium (D.S.).
  • Garg AX; Department of Medicine, Western University, London, Ontario, Canada (A.X.G.).
  • Short TG; Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand (T.G.S.).
  • Wittmann M; Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany (M.W.).
  • Meyhoff CS; Department of Anesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark (C.S.M.).
  • Amir M; Department of Surgery, Shifa International Hospital and Shifa Tameer-e-Millat University, Islamabad, Pakistan (M.A.).
  • Torres D; Departamento de Epidemiología y Estudios en Salud, Universidad de Los Andes, Santiago, Chile (D.T.).
  • Patel A; Department of Medicine, McMaster University, Hamilton, Ontario, Canada (A.P., V.T.).
  • Ruetzler K; Anesthesiology Institute, Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio (D.I.S., K.R., S.A., K.M., A.K.).
  • Parlow JL; Department of Anesthesiology and Perioperative Medicine, Queen's University, and Kingston Health Sciences Centre, Kingston, Ontario, Canada (J.L.P.).
  • Tandon V; Department of Medicine, McMaster University, Hamilton, Ontario, Canada (A.P., V.T.).
  • Fleischmann E; Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria (E.F.).
  • Polanczyk CA; UFRGS, Hospital de Clínicas de Porto Alegre, National Institute for Health Technology Assessment, IATS; Hospital Moinhos de Vento, Porto Alegre, Brazil (C.A.P.).
  • Lamy A; Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.).
  • Jayaram R; Department of Anaesthetics, Clinical Neurosciences, University of Oxford, Oxford University Hospitals NHS Trust, Oxford, United Kingdom (R.J.).
  • Astrakov SV; Department of Anesthesiology, Novosibirsk State University, Novosibirsk, Russia (S.V.A.).
  • Wu WKK; The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China (M.T.V.C., W.K.K.W.).
  • Cheong CC; Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia (C.Y.W., C.C.C.).
  • Ayad S; Anesthesiology Institute, Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio (D.I.S., K.R., S.A., K.M., A.K.).
  • Kirov M; Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russia (M.K.).
  • de Nadal M; Department of Anesthesiology and Intensive Care, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain (M. de N.).
  • Likhvantsev VV; V. Negovsky Reanimatology Research Institute, Moscow, Russia (V.V.L.).
  • Paniagua P; Anesthesiology Department, Santa Creu i Sant Pau University Hospital, Barcelona, Spain (P.P.).
  • Aguado HJ; Trauma & Orthopaedic Surgery Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain (H.J.A.).
  • Maheshwari K; Anesthesiology Institute, Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio (D.I.S., K.R., S.A., K.M., A.K.).
  • Whitlock RP; Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.).
  • McGillion MH; Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.).
  • Vincent J; Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.).
  • Copland I; Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.).
  • Balasubramanian K; Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.).
  • Biccard BM; Department of Anesthesia and Perioperative Medicine, Groote Schuur Hospital, and University of Cape Town, Cape Town, South Africa (B.M.B.).
  • Srinathan S; Section of Thoracic Surgery, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada (S.S.).
Ann Intern Med ; 176(5): 605-614, 2023 05.
Article en En | MEDLINE | ID: mdl-37094336
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.
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Texto completo: 1 Banco de datos: MEDLINE Asunto principal: Hipertensión / Hipotensión Tipo de estudio: Clinical_trials / Etiology_studies Límite: Humans País/Región como asunto: America do norte Idioma: En Revista: Ann Intern Med Año: 2023 Tipo del documento: Article
Texto completo
Imprimir
XML
PubMed Links
Buscar en Google

Texto completo: 1 Banco de datos: MEDLINE Asunto principal: Hipertensión / Hipotensión Tipo de estudio: Clinical_trials / Etiology_studies Límite: Humans País/Región como asunto: America do norte Idioma: En Revista: Ann Intern Med Año: 2023 Tipo del documento: Article