Among patients undergoing noncardiac surgery who are taking blood pressure (BP) medications, a multifaceted strategy to avoid hypotension immediately before, during and for up to two days after surgery made no difference in the rates of major cardiovascular events in the 30 days following surgery, according to findings from the POISE-3 trial presented April 4 at ACC.22.

Researchers looked at 7,490 patients enrolled in POISE-3 who were taking at least one BP medication to treat hypertension or other cardiovascular conditions. Patients were an average age of 70 years, 56% men, 72% on ACE inhibitors or ARBs, and they were randomly assigned to either a hypotension avoidance or hypertension avoidance strategy.

In the hypotension-avoidance group, ACE inhibitors or ARBs were withheld before surgery and for the first two days afterwards. For other types of BP medications, decisions on whether to continue or discontinue were based on the patient's systolic BP levels. Anesthesiologists in the operating rooms were asked to keep patients' mean arterial pressure (MAP) at or above 80 mm Hg throughout their surgery. On Day 3 post surgery or at discharge, patients could resume taking all their BP medications.

Meanwhile, in the hypertension-avoidance group, patients took their usual BP medications at the hospital before their operation. Their anesthesiologists were asked to keep their MAP at or above 60 mmHg throughout their surgery. After surgery, patients continued taking all their BP medications as usual.

The researchers found no difference between the two strategies for the primary endpoint – a composite of death from vascular disease and nonfatal heart injury, stroke or cardiac arrest at 30 days after surgery – as 14% of patients in each group experienced the primary endpoint.

In additional analyses, the researchers found that the average difference in BP and heart rate, at discrete times, between the two groups of patients was less than 2 mm Hg.

"We concluded that the most likely reason we found no difference between the two strategies was that they did not have a substantial differential impact on BP or heart rate during the perioperative period," said Maura Marcucci, MD, lead investigator of the study. "Our study answered two important questions that confront anesthesiologists, cardiologists and internists every day worldwide. It taught us that ensuring that patients' MAP remains above 60 throughout the surgery is safe and that targeting a higher MAP does not make a difference. Also, whether or not patients continued to take all of their chronic BP medications throughout the perioperative period did not make a real difference to their BP and heart rate and to major cardiovascular events."

Clinical Topics: Prevention, Hypertension

Keywords: ACC Annual Scientific Session, ACC22, Hypotension, Hypertension, Perioperative Care, Myocardial Infarction

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