Marcucci Maura, Chan Matthew T V, Painter Thomas W, Efremov Sergey, Aguado Hector J, Astrakov Sergey V, Kleinlugtenbelt Ydo V, Patel Ameen, Cata Juan P, Amir Mohammed, Kirov Mikhail, Leslie Kate, Duceppe Emmanuelle, Borges Flavia K, de Nadal Miriam, Tandon Vikas, Landoni Giovanni, Likhvantsev Valery V, Lomivorotov Vladimir, Sessler Daniel I, Martínez-Zapata María José, Xavier Denis, Fleischmann Edith, Wang Chew Yin, Meyhoff Christian S, Wittmann Maria, Torres David, Highton David, Jacka Michael, B Vishwanath, Zarnke Kelly, Sidhu Ravinder Singh, Oriani Giorgio, Ayad Sabry, Minear Steven, Weaver Tristan E, Ruetzler Kurt, Brusasco Claudia, Parlow Joel L, Maxwell Elizabeth, Miller Scott, Mrkobrada Marko, Bhatt Keyur Suresh Chandra, Rahate Prashant, Kowark Ana, De Blasio Giuseppe, Ofori Sandra N, Conen David, Srinathan Sadeesh, Szczeklik Wojciech, Jayaram Raja, Ellerkmann Richard K, Momeni Mona, Copland Ingrid, Vincent Jessica, Balasubramanian Kumar, Li Zhuoru, Wang Michael Ke, Li Deyang, McGillion Michael H, Kurz Andrea, Sharma Mukul, Short Timothy G, Devereaux P J
Population Health Research Institute, Hamilton, Ontario, Canada; Clinical Epidemiology and Research Centre, Humanitas University & IRCCS Humanitas Research Hospital, Milan, Italy; and Department of Health Research Methods, McMaster University, Hamilton, Ontario, Canada (M.Marcucci).
The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China (M.T.V.C.).
Ann Intern Med. 2025 Jul;178(7):909-920. doi: 10.7326/ANNALS-24-02841. Epub 2025 Jun 3.
Perioperative hemodynamic abnormalities have been associated with neurocognitive outcomes after noncardiac surgery.
To compare the effects of perioperative hypotension-avoidance versus hypertension-avoidance strategies on delirium and 1-year cognitive decline after noncardiac surgery.
Randomized controlled trial. (ClinicalTrials.gov: NCT03505723).
54 centers, 19 countries.
2603 high-vascular-risk patients undergoing noncardiac surgery, receiving 1 or more chronic antihypertensive medications (mean age, 70 years).
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.
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).
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.
The COVID-19 pandemic challenged site participation in the substudy; although large, the sample size was lower than expected.
There was no evidence of a difference in neurocognitive outcomes between the hypotension-avoidance and hypertension-avoidance strategies.
Canadian Institutes of Health Research, Canada; National Health and Medical Research Council, Australia; Research Grant Council, Hong Kong SAR, China.
围手术期血流动力学异常与非心脏手术后的神经认知结局相关。
比较围手术期避免低血压策略与避免高血压策略对非心脏手术后谵妄及1年认知功能下降的影响。
随机对照试验。（ClinicalTrials.gov：NCT03505723）。
19个国家的54个中心。
2603例接受非心脏手术、正在服用1种或更多种慢性抗高血压药物的高血管风险患者（平均年龄70岁）。
在避免低血压策略中，术中平均动脉压（MAP）目标为80 mmHg或更高；手术前及术后2天，停用肾素-血管紧张素-醛固酮系统抑制剂，按照算法，当收缩压达到130 mmHg或更高时给予其他慢性抗高血压药物。在避免高血压策略中，术中MAP目标为60 mmHg或更高；围手术期继续使用所有慢性抗高血压药物。
术后第1至3天的谵妄（主要结局）；与基线相比，术后1年蒙特利尔认知评估（MoCA）下降2分或更多（次要结局）。
避免低血压组1310例患者中有95例（7.3%）发生谵妄，避免高血压组1293例患者中有90例（7.0%）发生谵妄（相对危险度[RR]，1.04[95%CI，0.79至1.38]）。在701例完成1年MoCA（完整版或电话版）的患者中，避免低血压组347例中有129例（37.2%）、避免高血压组354例中有117例（33.1%）下降2分或更多（RR，1.13[CI，0.92至1.38]）。避免低血压组19%、避免高血压组27%的患者发生需要干预的低血压（RR，0.63[CI，0.52至0.76]），大多发生在术中；两组术后仅有5%的患者发生低血压。
2019冠状病毒病大流行影响了亚组研究中各研究点的参与情况；尽管样本量较大，但低于预期。
没有证据表明避免低血压策略和避免高血压策略在神经认知结局方面存在差异。
加拿大卫生研究院；澳大利亚国家卫生与医学研究委员会；中国香港特别行政区研究资助局。
