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

被引：83

作者：

Marcucci, Maura ^{[1
]}

Painter, Thomas W. ^{[2
]}

Conen, David ^{[1
]}

Lomivorotov, Vladimir ^{[3
]}

Sessler, Daniel, I ^{[4
]}

Chan, Matthew T. V. ^{[5
]}

Borges, Flavia K. ^{[1
]}

Leslie, Kate ^{[6
]}

Duceppe, Emmanuelle ^{[7
]}

Martinez-Zapata, Maria Jose ^{[8
]}

Wang, Chew Yin ^{[9
]}

Xavier, Denis ^{[10
]}

Ofori, Sandra N. ^{[1
]}

Wang, Michael Ke ^{[1
]}

Efremov, Sergey ^{[11
]}

Landoni, Giovanni ^{[12
]}

Kleinlugtenbelt, Ydo, V ^{[13
]}

Szczeklik, Wojciech ^{[14
]}

Schmartz, Denis ^{[15
]}

Garg, Amit X. ^{[16
]}

Short, Timothy G. ^{[17
]}

Wittmann, Maria ^{[18
]}

Meyhoff, Christian S. ^{[19
]}

Amir, Mohammed ^{[20
,21
]}

Torres, David ^{[22
]}

Patel, Ameen ^{[23
]}

Ruetzler, Kurt ^{[4
]}

Parlow, Joel L. ^{[24
,25
]}

Tandon, Vikas ^{[23
]}

Fleischmann, Edith ^{[26
]}

Polanczyk, Carisi A. ^{[27
,28
]}

Lamy, Andre ^{[1
]}

Jayaram, Raja ^{[29
]}

Astrakov, Sergey V. ^{[30
]}

Wu, William Ka Kei ^{[5
]}

Cheong, Chao Chia ^{[9
]}

Ayad, Sabry ^{[4
]}

Kirov, Mikhail ^{[31
]}

de Nadal, Miriam ^{[32
]}

Likhvantsev, Valery V. ^{[33
]}

Paniagua, Pilar ^{[34
]}

Aguado, Hector J. ^{[35
]}

Maheshwari, Kamal ^{[4
]}

Whitlock, Richard P. ^{[1
]}

McGillion, Michael H. ^{[1
]}

Vincent, Jessica ^{[1
]}

Copland, Ingrid ^{[1
]}

Balasubramanian, Kumar ^{[1
]}

Biccard, Bruce M. ^{[36
,37
]}

Srinathan, Sadeesh ^{[38
]}

机构：

[1] Populat Hlth Res Inst, Hamilton, ON, Canada

[2] Univ Adelaide, Acute Care Med, Adelaide, SA, Australia

[3] E Meshalkin Natl Med Res Ctr, Dept Anesthesiol & Intens Care, Novosibirsk, Russia

[4] Cleveland Clin, Anesthesiol Inst, Dept Outcomes Res, Cleveland, OH USA

[5] Chinese Univ Hong Kong, Hong Kong, Peoples R China

[6] Univ Melbourne, Melbourne Med Sch, Dept Crit Care Med, Melbourne, Vic, Australia

[7] Ctr Hosp Univ Montreal, Dept Med, Montreal, PQ, Canada

[8] IIB Sant Pau, Iberoamer Cochrane Ctr, Publ Hlth & Clin Epidemiol Serv, CIBERESP, Barcelona, Spain

[9] Univ Malaya, Fac Med, Dept Anesthesiol, Kuala Lumpur, Malaysia

[10] St Johns Med Coll, Bangalore, India

[11] St Petersburg State Univ Hosp, St Petersburg, Russia

[12] Univ Vita Salute San Raffaele, IRCCS San Raffaele Sci Inst, Dept Anesthesiol & Intens Care, Milan, Italy

[13] Deventer Ziekenhuis, Dept Orthoped & Trauma Surg, Deventer, Netherlands

[14] Jagiellonian Univ, Ctr Intens Care & Perioperat Med, Med Coll, Krakow, Poland

[15] Univ Libre Bruxelles, CHU Brugmann, Brussels, Belgium

[16] Western Univ, Dept Med, London, ON, Canada

[17] Auckland City Hosp, Dept Anaesthesia, Auckland, New Zealand

[18] Univ Hosp Bonn, Dept Anesthesiol & Intens Care Med, Bonn, Germany

[19] Copenhagen Univ Hosp Bispebjerg & Frederiksberg, Dept Anesthesia & Intens Care, Copenhagen, Denmark

[20] Shifa Int Hosp, Dept Surg, Islamabad, Pakistan

[21] Shifa Tameer e Millat Univ, Islamabad, Pakistan

[22] Univ Los Andes, Dept Epidemiol & Estudios Salud, Santiago, Chile

[23] McMaster Univ, Dept Med, Hamilton, ON, Canada

[24] Queens Univ, Dept Anesthesiol & Perioperat Med, Kingston, ON, Canada

[25] Kingston Hlth Sci Ctr, Kingston, ON, Canada

[26] Med Univ Vienna, Dept Anesthesia Intens Care Med & Pain Med, Vienna, Austria

[27] Univ Fed Rio Grande do Sul, Hosp Clin Porto Alegre, Natl Inst Hlth Technol Assessment, IATS, Porto Alegre, Brazil

[28] Hosp Moinhos de Vento, Porto Alegre, Brazil

[29] Univ Oxford, Oxford Univ Hosp NHS Trust, Dept Anaesthet, Clin Neurosci, Oxford, England

[30] Novosibirsk State Univ, Dept Anesthesiol, Novosibirsk, Russia

[31] Northern State Med Univ, Dept Anesthesiol & Intens Care Med, Arkhangelsk, Russia

[32] Univ Autonoma Barcelona, Hosp Vall Hebron, Dept Anesthesiol & Intens Care, Barcelona, Spain

[33] V Negovsky Reanimatol Res Inst, Moscow, Russia

[34] Santa Creu & Sant Pau Univ Hosp, Anesthesiol Dept, Barcelona, Spain

[35] Hosp Clin Univ Valladolid, Trauma & Orthopaed Surg Dept, Valladolid, Spain

[36] Groote Schuur Hosp, Dept Anesthesia & Perioperat Med, Cape Town, South Africa

[37] Univ Cape Town, Cape Town, South Africa

[38] Univ Manitoba, Dept Surg, Sect Thorac Surg, Winnipeg, MB, Canada

[39] McMaster Univ, Dept Hlth Res Methods Evidence & Impact, Hamilton, ON, Canada

来源：

ANNALS OF INTERNAL MEDICINE | 2023年 / 176卷 / 05期

基金：

英国医学研究理事会; 加拿大健康研究院;

关键词：

MEAN ARTERIAL-PRESSURE; BLOOD-PRESSURE; 30-DAY MORTALITY; MYOCARDIAL INJURY; TROPONIN LEVELS; ACUTE KIDNEY; RISK; ASSOCIATION; COHORT; MANAGEMENT;

D O I：

10.7326/M22-3157

中图分类号：

R5 [内科学];

学科分类号：

1002 ; 100201 ;

摘要：

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.

引用

页码：605 / +

页数：11

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