Cognitive outcomes similar after noncardiac surgery whether perioperative hypotension- or hypertension-avoidance strategies employed

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Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent.   
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Cognitive outcomes similar after noncardiac surgery whether perioperative hypotension- or hypertension-avoidance strategies employed 

Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-24-02841  

Editorial: https://www.acpjournals.org/doi/10.7326/ANNALS-25-01409  

URL goes live when the embargo lifts               

A randomized controlled trial compared the effect of hypotension-avoidance versus hypertension-avoidance strategies on delirium and one-year cognitive decline after non-cardiac surgery. The study found no differences in neurocognitive outcomes between the two perioperative blood pressure strategies, further emphasizing previous research that found a lack of difference in clinically important outcomes between these two strategies. According to the researchers, this is the largest existing trial evaluating interventions targeting neurocognitive outcomes after noncardiac surgery. The study is published in Annals of Internal Medicine.   

McMaster University/Population Health Research Institute, Humanitas University, and colleagues studied 2,603 high-vascular-risk adult patients who had major noncardiac surgery at 54 centers in 19 countries. The researchers aimed to compare the effects on postoperative delirium and one-year cognitive decline of two blood pressure management strategies that differ in intraoperative mean arterial pressure (MAP) targets and in perioperative management of chronic antihypertensive medications. Patients were randomized to either a hypotension-avoidance strategy (intraoperative MAP target ≥80 mm Hg; chronic renin–angiotensin system inhibitors [RASI] withheld perioperatively, and other chronic antihypertensive medications continued based on patient blood pressure) or a hypertension-avoidance strategy (intraoperative MAP target ≥60 mm Hg; all chronic antihypertensive medications continued perioperatively) and were screened for delirium twice daily from the first day after surgery until postoperative day three, discharge or delirium diagnosis, whichever came first, using a three-minute diagnostic interview. 1,001 patients were enrolled in the one-year cognitive decline evaluation. The researchers found that delirium occurred in 7.3% of patients in the hypotension-avoidance group and 7% of patients in the hypertension-avoidance group. The median delirium severity score among patients with delirium was 4.0 in both groups. A similar proportion of patients in the two groups had cognitive decline one year after surgery. The findings do not support targeting an intraoperative MAP ≥80 mm Hg, compared with a MAP ≥60 mm Hg, and withholding RASI and continuing other chronic antihypertensive medications following an algorithm, compared with continuing all chronic antihypertensive medications, to improve postoperative neurocognitive outcomes.  

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To contact corresponding author Maura Marcucci, MD, please email Adam Ward at warda17@mcmaster.ca  or Francesca Barocco at francesca.barocco@humanitas.it.  

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