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Marcucci, M; Chan, MTV; Painter, TW; Efremov, S; Aguado, HJ; Astrakov, SV; Kleinlugtenbelt, YV; Patel, A; Cata, JP; Amir, M; Kirov, M; Leslie, K; Duceppe, E; Borges, FK; de, Nadal, M; Tandon, V; Landoni, G; Likhvantsev, VV; Lomivorotov, V; Sessler, DI; Martínez-Zapata, MJ; Xavier, D; Fleischmann, E; Wang, CY; Meyhoff, CS; Wittmann, M; Torres, D; Highton, D; Jacka, M; B, V; Zarnke, K; Sidhu, RS; Oriani, G; Ayad, S; Minear, S; Weaver, TE; Ruetzler, K; Brusasco, C; Parlow, JL; Maxwell, E; Miller, S; Mrkobrada, M; Bhatt, KSC; Rahate, P; Kowark, A; De, Blasio, G; Ofori, SN; Conen, D; Srinathan, S; Szczeklik, W; Jayaram, R; Ellerkmann, RK; Momeni, M; Copland, I; Vincent, J; Balasubramanian, K; Li, Z; Wang, MK; Li, D; McGillion, MH; Kurz, A; Sharma, M; Short, TG; Devereaux, PJ, , cogPOISE-3, Trial, Investigators, and, Study, Groups.
Effects of a Hypotension-Avoidance Versus a Hypertension-Avoidance Strategy on Neurocognitive Outcomes After Noncardiac Surgery.
Ann Intern Med. 2025; Doi: 10.7326/ANNALS-24-02841
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Co-Autor*innen der Med Uni Graz
Kurz Andrea
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Abstract:
BACKGROUND: Perioperative hemodynamic abnormalities have been associated with neurocognitive outcomes after noncardiac surgery. OBJECTIVE: To compare the effects of perioperative hypotension-avoidance versus hypertension-avoidance strategies on delirium and 1-year cognitive decline after noncardiac surgery. DESIGN: Randomized controlled trial. (ClinicalTrials.gov: NCT03505723). SETTING: 54 centers, 19 countries. PARTICIPANTS: 2603 high-vascular-risk patients undergoing noncardiac surgery, receiving 1 or more chronic antihypertensive medications (mean age, 70 years). INTERVENTION: In the hypotension-avoidance strategy, the intraoperative mean arterial pressure (MAP) target was 80 mm Hg or greater; before and for 2 days after surgery, renin-angiotensin-aldosterone system inhibitors were withheld, and other chronic antihypertensive medications were administered for systolic blood pressures of 130 mm Hg or greater following an algorithm. In the hypertension-avoidance strategy, the intraoperative MAP target was 60 mm Hg or greater; all chronic antihypertensive medications were continued perioperatively. MEASUREMENTS: Delirium on postoperative day 1 to 3 (primary outcome); decline of 2 points or more at the Montreal Cognitive Assessment (MoCA) 1 year after surgery compared with baseline (secondary outcome). RESULTS: 95 of 1310 patients (7.3%) in the hypotension-avoidance and 90 of 1293 patients (7.0%) in the hypertension-avoidance group had delirium (relative risk [RR], 1.04 [95% CI, 0.79 to 1.38]). Among 701 patients who completed 1-year MoCA (full or telephone version), 129 of 347 (37.2%) in the hypotension-avoidance and 117 of 354 (33.1%) in the hypertension-avoidance group had a decline of 2 or more points (RR, 1.13 [CI, 0.92 to 1.38]). Nineteen percent in the hypotension-avoidance and 27% in the hypertension-avoidance strategy had hypotension requiring an intervention (RR, 0.63 [CI, 0.52 to 0.76]), mostly intraoperatively; only 5%, in both groups, had hypotension postoperatively. LIMITATION: The COVID-19 pandemic challenged site participation in the substudy; although large, the sample size was lower than expected. CONCLUSION: There was no evidence of a difference in neurocognitive outcomes between the hypotension-avoidance and hypertension-avoidance strategies. PRIMARY FUNDING SOURCE: Canadian Institutes of Health Research, Canada; National Health and Medical Research Council, Australia; Research Grant Council, Hong Kong SAR, China.

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