Targeting Higher Intraoperative Blood Pressures Does Not Reduce Adverse Cardiovascular Events Following Noncardiac Surgery

J Am Coll Cardiol. 2021 Nov 2;78(18):1753-1764. doi: 10.1016/j.jacc.2021.08.048.

Abstract

Background: Intraoperative arterial hypotension is strongly associated with postoperative major adverse cardiovascular events (MACE); however, whether targeting higher intraoperative mean arterial blood pressures (MAPs) may prevent adverse events remains unclear.

Objectives: This study sought to determine whether targeting higher intraoperative MAP lowers the incidence of postoperative MACE.

Methods: This single-center randomized controlled trial assigned adult patients at cardiovascular risk undergoing major noncardiac surgery to an intraoperative MAP target of ≥60 mm Hg (control) or ≥75 mm Hg (MAP ≥75). The primary outcome was acute myocardial injury on postoperative days 0-3 and/or 30-day MACE/acute kidney injury (AKI) (acute coronary syndrome, congestive heart failure, coronary revascularization, stroke, AKI, and all-cause mortality). The secondary outcome was 1-year MACE.

Results: In total, 458 patients were randomized (intention-to-treat population: 451). The cumulative intraoperative duration with MAP <65 mm Hg was significantly shorter in the MAP ≥75 group (median 9 minutes [interquartile range: 3 to 24 minutes] vs 23 minutes [interquartile range: 8-49 minutes]; P < 0.001). The primary outcome incidence was 48% for MAP ≥75 and 52% for control (risk difference -4.2%; 95% CI: -13% to +5%), the primary contributor being AKI (incidence 44%). Acute myocardial injury occurred in 15% (MAP ≥75) and 19% (control) of patients. The secondary outcome incidence was 17% for MAP ≥75 and 15% for control (risk difference +2.7; 95% CI: -4% to +9.5%).

Conclusions: These findings do not support universally targeting higher intraoperative blood pressures to reduce postoperative complications. Despite a 60% reduction in hypotensive time with MAP <65 mm Hg, no significant reductions in acute myocardial injury or 30-day MACE/AKI could be found. (Biomarkers, Blood Pressure, BIS: Risk Stratification/Management of Patients at Cardiac Risk in Major Noncardiac Surgery [BBB]; NCT02533128).

Keywords: MACE; blood pressure; hypotension; intraoperative; myocardial injury; organ injury.

Publication types

  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Acute Coronary Syndrome* / diagnosis
  • Acute Coronary Syndrome* / etiology
  • Acute Coronary Syndrome* / therapy
  • Acute Kidney Injury* / diagnosis
  • Acute Kidney Injury* / etiology
  • Blood Pressure / drug effects
  • Blood Pressure Determination / methods*
  • Female
  • General Surgery / methods
  • Heart Failure* / diagnosis
  • Heart Failure* / etiology
  • Humans
  • Male
  • Middle Aged
  • Myocardial Revascularization / statistics & numerical data*
  • Outcome and Process Assessment, Health Care
  • Patient Care Management / methods
  • Patient Care Management / standards
  • Perioperative Care / methods
  • Perioperative Care / statistics & numerical data
  • Postoperative Complications* / etiology
  • Postoperative Complications* / prevention & control
  • Postoperative Complications* / therapy
  • Risk Adjustment / methods
  • Stroke* / diagnosis
  • Stroke* / etiology

Associated data

  • ClinicalTrials.gov/NCT02533128