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

Patrick M Wanner, Dirk U Wulff, Mirjana Djurdjevic, Wolfgang Korte, Thomas Schnider & Miodrag Filipovic

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 ≥). 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 ≥ 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 ≥ 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 ≥) and 19% (control) of patients. The secondary outcome incidence was 17% for MAP ≥ 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).
   
citation Wanner P M, Wulff D U, Djurdjevic M, Korte W, Schnider T, Filipovic M. Targeting Higher Intraoperative Blood Pressures Does Not Reduce Adverse Cardiovascular Events Following Noncardiac Surgery. J Am Coll Cardiol 2021; 78:1753-1764.
   
type journal paper/review (English)
date of publishing 2021
journal title J Am Coll Cardiol (78/18)
ISSN electronic 1558-3597
pages 1753-1764
PubMed 34711333
DOI 10.1016/j.jacc.2021.08.048