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21 décembre 2023

Marcucci M, Painter TW, Conen D, et al. ; POISE-3 Trial Investigators and Study Groups. Hypotension-Avoidance Versus Hypertension-Avoidance Strategies in Noncardiac Surgery : An International Randomized Controlled Trial. Ann Intern Med. 2023 May ;176(5):605-614. doi : 10.7326/M22-3157IF : 39.2 Q1 . Epub 2023 Apr 25. PMID : 37094336.

Background : 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 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.

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.