Marcucci, M.Painter, T.W.Conen, D.Lomivorotov, V.Sessler, D.I.Chan, M.T.V.Borges, F.K.Leslie, K.Duceppe, E.Martínez-Zapata, M.J.Wang, C.Y.Xavier, D.Ofori, S.N.Wang, M.K.Efremov, S.Landoni, G.Kleinlugtenbelt, Y.V.Szczeklik, W.Schmartz, D.Garg, A.X.et al.2023-06-062023-06-062023Annals of Internal Medicine, 2023; 176(5):605-6140003-48191539-3704https://hdl.handle.net/2440/138675Background: Among 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. Objective: To compare the effects of a hypotension-avoidance and a hypertension-avoidance strategy on major vascular complications after noncardiac surgery. Design: Partial factorial randomized trial of 2 perioperative blood pressure management strategies (reported here) and tranexamic acid versus placebo. (ClinicalTrials.gov: NCT03505723) Setting: 110 hospitals in 22 countries. Patients: 7490 patients having noncardiac surgery who were at risk for vascular complications and were receiving 1 or more long-term antihypertensive medications. Intervention: In the hypotension-avoidance strategy group, the intraoperative mean arterial pressure target was 80mm 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 130mm Hg or greater, following an algorithm. In the hypertension-avoidance strategy group, the intraoperative mean arterial pressure target was 60mm Hg or greater; all antihypertensive medications were continued before and after surgery. Measurements: The 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. Results: The 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. Limitation: Adherence to the assigned strategies was suboptimal; however, results were consistent across different adherence levels. Conclusion: In patients having noncardiac surgery, our hypotension-avoidance and hypertension-avoidance strategies resulted in a similar incidence of major vascular complications.en© 2023 American College of PhysiciansPOISE-3 Trial Investigators and Study GroupsHumansHypertensionHypotensionPostoperative ComplicationsAntihypertensive AgentsCanadaJournal article10.7326/M22-31572023-06-06643597Painter, T.W. [0000-0003-2216-2046]