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

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 [interquartite 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) (C) 2021 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation.

Automated summary

This study found that targeting higher intraoperative mean arterial blood pressures (75 mm Hg) in cardiovascular risk patients undergoing major noncardiac surgery did not significantly reduce the incidence of postoperative major adverse cardiovascular events. Despite a shorter duration of hypotensive time during surgery, there were no significant differences in outcomes such as acute myocardial injury and 30-day MACE/AKI between the higher and lower blood pressure target groups.