TY - JOUR

T1 - Effects of a Hypotension-Avoidance Versus a Hypertension-Avoidance Strategy on Neurocognitive Outcomes After Noncardiac Surgery

AU - cogPOISE-3 Trial Investigators and Study Groups

AU - Marcucci, Maura

AU - Chan, Matthew T.v.

AU - Painter, Thomas W.

AU - Efremov, Sergey

AU - Aguado, Hector J.

AU - Astrakov, Sergey V.

AU - Kleinlugtenbelt, Ydo V.

AU - Patel, Ameen

AU - Cata, Juan P.

AU - Amir, Mohammed

AU - Kirov, Mikhail

AU - Leslie, Kate

AU - Duceppe, Emmanuelle

AU - Borges, Flavia K.

AU - De Nadal, Miriam

AU - Tandon, Vikas

AU - Landoni, Giovanni

AU - Likhvantsev, Valery V.

AU - Lomivorotov, Vladimir

AU - Sessler, Daniel I.

AU - Martínez-zapata, María José

AU - Xavier, Denis

AU - Fleischmann, Edith

AU - Wang, Chew Yin

AU - Meyhoff, Christian S.

AU - Wittmann, Maria

AU - Torres, David

AU - Highton, David

AU - Jacka, Michael

AU - B, Vishwanath

AU - Zarnke, Kelly

AU - Sidhu, Ravinder Singh

AU - Oriani, Giorgio

AU - Ayad, Sabry

AU - Minear, Steven

AU - Weaver, Tristan E.

AU - Ruetzler, Kurt

AU - Brusasco, Claudia

AU - Parlow, Joel L.

AU - Maxwell, Elizabeth

AU - Miller, Scott

AU - Mrkobrada, Marko

AU - Bhatt, Keyur Suresh Chandra

AU - Rahate, Prashant

AU - Kowark, Ana

AU - De Blasio, Giuseppe

AU - Ofori, Sandra N.

AU - Conen, David

AU - Srinathan, Sadeesh

AU - Efremov, Sergey

PY - 2025/7/1

Y1 - 2025/7/1

N2 - BACKGROUND: Perioperative hemodynamic abnormalities have been associated with neurocognitive outcomes after noncardiac surgery.OBJECTIVE: To compare the effects of perioperative hypotension-avoidance versus hypertension-avoidance strategies on delirium and 1-year cognitive decline after noncardiac surgery.DESIGN: Randomized controlled trial. (ClinicalTrials.gov: NCT03505723).SETTING: 54 centers, 19 countries.PARTICIPANTS: 2603 high-vascular-risk patients undergoing noncardiac surgery, receiving 1 or more chronic antihypertensive medications (mean age, 70 years).INTERVENTION: In the hypotension-avoidance strategy, the intraoperative mean arterial pressure (MAP) target was 80 mm Hg or greater; before and for 2 days after surgery, renin-angiotensin-aldosterone system inhibitors were withheld, and other chronic antihypertensive medications were administered for systolic blood pressures of 130 mm Hg or greater following an algorithm. In the hypertension-avoidance strategy, the intraoperative MAP target was 60 mm Hg or greater; all chronic antihypertensive medications were continued perioperatively.MEASUREMENTS: Delirium on postoperative day 1 to 3 (primary outcome); decline of 2 points or more at the Montreal Cognitive Assessment (MoCA) 1 year after surgery compared with baseline (secondary outcome).RESULTS: 95 of 1310 patients (7.3%) in the hypotension-avoidance and 90 of 1293 patients (7.0%) in the hypertension-avoidance group had delirium (relative risk [RR], 1.04 [95% CI, 0.79 to 1.38]). Among 701 patients who completed 1-year MoCA (full or telephone version), 129 of 347 (37.2%) in the hypotension-avoidance and 117 of 354 (33.1%) in the hypertension-avoidance group had a decline of 2 or more points (RR, 1.13 [CI, 0.92 to 1.38]). Nineteen percent in the hypotension-avoidance and 27% in the hypertension-avoidance strategy had hypotension requiring an intervention (RR, 0.63 [CI, 0.52 to 0.76]), mostly intraoperatively; only 5%, in both groups, had hypotension postoperatively.LIMITATION: The COVID-19 pandemic challenged site participation in the substudy; although large, the sample size was lower than expected.CONCLUSION: There was no evidence of a difference in neurocognitive outcomes between the hypotension-avoidance and hypertension-avoidance strategies.PRIMARY FUNDING SOURCE: Canadian Institutes of Health Research, Canada; National Health and Medical Research Council, Australia; Research Grant Council, Hong Kong SAR, China.

AB - BACKGROUND: Perioperative hemodynamic abnormalities have been associated with neurocognitive outcomes after noncardiac surgery.OBJECTIVE: To compare the effects of perioperative hypotension-avoidance versus hypertension-avoidance strategies on delirium and 1-year cognitive decline after noncardiac surgery.DESIGN: Randomized controlled trial. (ClinicalTrials.gov: NCT03505723).SETTING: 54 centers, 19 countries.PARTICIPANTS: 2603 high-vascular-risk patients undergoing noncardiac surgery, receiving 1 or more chronic antihypertensive medications (mean age, 70 years).INTERVENTION: In the hypotension-avoidance strategy, the intraoperative mean arterial pressure (MAP) target was 80 mm Hg or greater; before and for 2 days after surgery, renin-angiotensin-aldosterone system inhibitors were withheld, and other chronic antihypertensive medications were administered for systolic blood pressures of 130 mm Hg or greater following an algorithm. In the hypertension-avoidance strategy, the intraoperative MAP target was 60 mm Hg or greater; all chronic antihypertensive medications were continued perioperatively.MEASUREMENTS: Delirium on postoperative day 1 to 3 (primary outcome); decline of 2 points or more at the Montreal Cognitive Assessment (MoCA) 1 year after surgery compared with baseline (secondary outcome).RESULTS: 95 of 1310 patients (7.3%) in the hypotension-avoidance and 90 of 1293 patients (7.0%) in the hypertension-avoidance group had delirium (relative risk [RR], 1.04 [95% CI, 0.79 to 1.38]). Among 701 patients who completed 1-year MoCA (full or telephone version), 129 of 347 (37.2%) in the hypotension-avoidance and 117 of 354 (33.1%) in the hypertension-avoidance group had a decline of 2 or more points (RR, 1.13 [CI, 0.92 to 1.38]). Nineteen percent in the hypotension-avoidance and 27% in the hypertension-avoidance strategy had hypotension requiring an intervention (RR, 0.63 [CI, 0.52 to 0.76]), mostly intraoperatively; only 5%, in both groups, had hypotension postoperatively.LIMITATION: The COVID-19 pandemic challenged site participation in the substudy; although large, the sample size was lower than expected.CONCLUSION: There was no evidence of a difference in neurocognitive outcomes between the hypotension-avoidance and hypertension-avoidance strategies.PRIMARY FUNDING SOURCE: Canadian Institutes of Health Research, Canada; National Health and Medical Research Council, Australia; Research Grant Council, Hong Kong SAR, China.

KW - Aged

KW - Female

KW - Humans

KW - Male

KW - Middle Aged

KW - Antihypertensive Agents/therapeutic use

KW - Cognitive Dysfunction/prevention & control

KW - Delirium/prevention & control

KW - Hypertension/prevention & control

KW - Hypotension/prevention & control

KW - Postoperative Cognitive Complications/prevention & control

KW - Postoperative Complications/prevention & control

KW - Surgical Procedures, Operative/adverse effects

UR - https://www.mendeley.com/catalogue/5f253039-ad43-3edb-aeb7-7ebf97cf9d48/

U2 - 10.7326/annals-24-02841

DO - 10.7326/annals-24-02841

M3 - Article

C2 - 40456161

VL - 178

SP - 909

EP - 920

JO - Annals of Internal Medicine

JF - Annals of Internal Medicine

SN - 0003-4819

IS - 7

ER -