Effects of a Hypotension-Avoidance Versus a Hypertension-Avoidance Strategy on Neurocognitive Outcomes After Noncardiac Surgery
Maura Marcucci, Matthew T.V. Chan, Thomas Painter, Sergey Efremov, Héctor J. Hernández, Sergey V. Astrakov, Ydo V. Kleinlugtenbelt, Ameen Patel, Juan P. Cata, Mohammed Amir, М. Yu. Кirov, Kate Leslie, Emmanuelle Duceppe, Flávia K. Borges, Miriam de Nadal, Vikas Tandon, Giovanni Landoni, В. В. Лихванцев, В. Н. Ломиворотов, Daniel I. Sessler, María José Martínez-Zapata, Denis Xavier, Edith Fleischmann, Chew Yin Wang, Christian S. Meyhoff, Maria Wittmann, David Torres, David Highton, Michael J. Jacka, Bannikuppe S. Vishwanath, Kelly B. Zarnke, Ravinder Singh Sidhu, G. Oriani, Sabry Ayad, Steven Minear, Tristan Weaver, Kurt Ruetzler, Claudia Brusasco, Joel L. Parlow, Elizabeth Maxwell, Scott Miller, Marko Mrkobrada, Bhatt Keyur, Prashant Rahate, Ana Kowark, Giuseppe De Blasio, Sandra Ofori, David Conen, Sadeesh Srinathan, Wojciech Szczeklik, Raja Jayaram, Richard K. Ellerkmann, Mona Momeni, Ingrid Copland, Jessica Vincent, Kumar Balasubramanian, Zhuoru Li, Michael Ke Wang, Deyang Li, Michael McGillion, Andrea Kurz, Mukul Sharma, Timothy G. Short, P.J. Devereaux, cogPOISE-3 Trial Investigators and Study Groups, Maura Marcucci, Matthew T.V. Chan, Thomas Painter, Sergey Efremov, Hector J. Aguado, Sergey V. Astrakov, Ydo V. Kleinlugtenbelt, Ameen Patel, Juan P. Cata, Mohammed Amir, М. Yu. Кirov, Kate Leslie, Emmanuelle Duceppe, Flávia K. Borges, Miriam de Nadal, Vikas Tandon, Giovanni Landoni, В. В. Лихванцев, В. Н. Ломиворотов, Daniel I. Sessler, María José Martínez-Zapata, Denis Xavier, Edith Fleischmann, Chew Yin Wang, Christian S. Meyhoff, Maria Wittmann, David Torres, David Highton, Michael J. Jacka, Bannikuppe S. Vishwanath, Kelly B. Zarnke, Ravinder Singh Sidhu, G. Oriani, Sabry Ayad, Steven Minear
Abstract
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.