Clinical question: In patients on antihypertensive medications (AHMs) such as angiotensin-converting-enzyme inhibitors (ACE-Is) or angiotensin receptor blockers (ARBs) undergoing inpatient non-cardiac surgery, what blood pressure (BP) management strategy reduces the risk of major vascular complications?
Background: Perioperatively, both hypotension and hypertension can lead to vascular complications after non-cardiac surgery. There is a lack of large robust trials that inform how AHMs should be managed; there is conflicting data regarding what the minimal intraoperative mean arterial pressure should be to reduce complications.
Study design: Randomized controlled trial comparing two perioperative BP management strategies
Setting: 110 hospitals across 22 countries, from July 2018 to July 2021
Synopsis: Using the measure accurately, act rapidly, and partner with patients (MAP) measurement techniques, 7,490 patients with vascular risk factors and taking at least one AHM were randomized to either a hypotension-avoidance strategy (step-wise AHM addition for SBP >130 mmg Hg on days 0-2 after surgery, avoidance of ACE-I and ARBs on the night before and days 0-3 after surgery; intraoperative MAP target >80mm Hg), or a hypertension-avoidance strategy (continuation of all chronic AHMs before and after surgery, intraoperative MAP target 60 mm Hg). The mean age was 70 years, patients took a mean of two AHMs with a majority taking ACE-I or ARBS and/or beta-blockers. The primary outcome, a composite of vascular death, non-fatal myocardial injury, stroke, and cardiac arrest at 30 days, occurred in 13.9% of the hypotension-avoidance group and in 14% of the hypertension-avoidance group. Despite more significant hypotensive episodes in the hypertension-avoidance arm, this did not translate to higher major vascular complications. Limitations of the study include suboptimal adherence to treatment strategies and short-term 30-day follow-up.
Bottom line: For inpatient non-cardiac surgeries, there’s no difference in major vascular complication risk between hypotension- or hypertension-avoidance strategies, regardless of withholding ACE-I or ARBs.
Citation: Marcucci M, et al. Hypotension-avoidance versus hypertension-avoidance strategies in noncardiac surgery: An international randomized controlled trial. Ann Intern Med. 2023;176(5):605-14.
Dr. Subramany is a hospitalist and assistant professor of medicine at the University of New Mexico Hospital, Albuquerque, N.M.