• Maura Marcucci, Thomas W Painter, David Conen, Vladimir Lomivorotov, Daniel I Sessler, ChanMatthew T VMTV0000-0002-3574-7855The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China (M.T.V.C., W.K.K.W.)., Flavia K Borges, Kate Leslie, Emmanuelle Duceppe, María José Martínez-Zapata, Chew Yin Wang, Denis Xavier, Sandra N Ofori, Michael Ke Wang, Sergey Efremov, Giovanni Landoni, Ydo V Kleinlugtenbelt, Wojciech Szczeklik, Denis Schmartz, Amit X Garg, Timothy G Short, Maria Wittmann, Christian S Meyhoff, Mohammed Amir, David Torres, Ameen Patel, Kurt Ruetzler, Joel L Parlow, Vikas Tandon, Edith Fleischmann, Carisi A Polanczyk, Andre Lamy, Raja Jayaram, Sergey V Astrakov, WuWilliam Ka KeiWKK0000-0002-5662-5240The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China (M.T.V.C., W.K.K.W.)., Chao Chia Cheong, Sabry Ayad, Mikhail Kirov, Miriam de Nadal, Valery V Likhvantsev, Pilar Paniagua, Hector J Aguado, Kamal Maheshwari, Richard P Whitlock, Michael H McGillion, Jessica Vincent, Ingrid Copland, Kumar Balasubramanian, Bruce M Biccard, Sadeesh Srinathan, Samandar Ismoilov, Shirley Pettit, David Stillo, Andrea Kurz, Emilie P Belley-Côté, Jessica Spence, William F McIntyre, Shrikant I Bangdiwala, Gordon Guyatt, Salim Yusuf, P J Devereaux, and POISE-3 Trial Investigators and Study Groups.
• Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.).
• Ann. Intern. Med. 2023 May 1; 176 (5): 605614605-614.

BackgroundAmong patients having noncardiac surgery, perioperative hemodynamic abnormalities are associated with vascular complications. Uncertainty remains about what intraoperative blood pressure to target and how to manage long-term antihypertensive medications perioperatively.ObjectiveTo compare the effects of a hypotension-avoidance and a hypertension-avoidance strategy on major vascular complications after noncardiac surgery.DesignPartial factorial randomized trial of 2 perioperative blood pressure management strategies (reported here) and tranexamic acid versus placebo. (ClinicalTrials.gov: NCT03505723).Setting110 hospitals in 22 countries.Patients7490 patients having noncardiac surgery who were at risk for vascular complications and were receiving 1 or more long-term antihypertensive medications.InterventionIn the hypotension-avoidance strategy group, the intraoperative mean arterial pressure target was 80 mm Hg or greater; before and for 2 days after surgery, renin-angiotensin-aldosterone system inhibitors were withheld and the other long-term antihypertensive medications were administered only for systolic blood pressures 130 mm Hg or greater, following an algorithm. In the hypertension-avoidance strategy group, the intraoperative mean arterial pressure target was 60 mm Hg or greater; all antihypertensive medications were continued before and after surgery.MeasurementsThe primary outcome was a composite of vascular death and nonfatal myocardial injury after noncardiac surgery, stroke, and cardiac arrest at 30 days. Outcome adjudicators were masked to treatment assignment.ResultsThe primary outcome occurred in 520 of 3742 patients (13.9%) in the hypotension-avoidance group and in 524 of 3748 patients (14.0%) in the hypertension-avoidance group (hazard ratio, 0.99 [95% CI, 0.88 to 1.12]; P = 0.92). Results were consistent for patients who used 1 or more than 1 antihypertensive medication in the long term.LimitationAdherence to the assigned strategies was suboptimal; however, results were consistent across different adherence levels.ConclusionIn patients having noncardiac surgery, our hypotension-avoidance and hypertension-avoidance strategies resulted in a similar incidence of major vascular complications.Primary Funding SourceCanadian Institutes of Health Research, National Health and Medical Research Council (Australia), and Research Grant Council of Hong Kong.

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