CLINICAL QUESTION: Does perioperative hypotension avoidance versus hypertension avoidance carry an increased risk of postoperative delirium or cognitive decline? BACKGROUND: There is concern that increased rates of intraoperative hypotension can lead to an increased risk of postoperative delirium or cognitive decline, while various observational studies have implicated both intraoperative hypotension and hypertension.
STUDY DESIGN: Randomized, controlled, multi-center, unblinded trial
SETTING: 54 centers across 19 countries
SYNOPSIS: The cogPOISE-3 Trial (a sub-study of POISE-3) randomized patients undergoing non-cardiac surgery who were on chronic antihypertensives, over age 45, and without dementia to the two blood pressure management strategies, comparing rates of postoperative delirium and evidence of cognitive decline. This was the largest, and first multicenter, trial regarding this question to date.
Using the 3-Minute Diagnostic Interview for Confusion Assessment Method (3D-CAM) (or Confusion Assessment Method for the ICU, or CAM-ICU, when appropriate), 95 of 1,310 (7.3%) patients in the hypotension-avoidance group and 90 of 1,293 (7.0%) in the hypertension-avoidance group experienced delirium, a relative risk of 1.04 (95% CI, 0.79 to 1.38).
The primary analysis for cognitive decline used a decrease of more than two points on the Montreal Cognitive Assessment from baseline findings at one year, with 129 of 347 (37.2%) patients in the hypotension-avoidance group and 117 of 354 (33.1%) in the hypertension-avoidance group meeting this criterion, a relative risk of 1.13 (CI, 0.92 to 1.38).
The rate of intraoperative hypotension requiring intervention was 19% in the hypotension-avoidance and 27% in the hypertension-avoidance group, a relative risk of 0.63 (CI, 0.52 to 0.76). Rapid identification of intraoperative hypotension and intervention likely limited impact on clinical outcomes.
BOTTOM LINE: There was no effect on postoperative delirium or cognitive decline at one year between the hypotension-avoidance or hypertension-avoidance strategy.
CITATION: Marcucci M, et al. Effects of a hypotension-avoidance versus a hypertension-avoidance strategy on neurocognitive outcomes after noncardiac surgery. Ann Intern Med. 2025;178(7):909-920. doi: 10.7326/ANNALS-24-02841.
Dr. Pachunka
Dr. Pachunka is a med-peds internal medicine hospitalist and outpatient internal medicine-pediatrics practitioner at the Nebraska Medical Center and an assistant professor at the University of Nebraska Medical Center, both in Omaha, Neb.