Article Impact Level: HIGH Data Quality: STRONG Summary of Annals of Internal Medicine, ANNALS-24-02841. https://doi.org/10.7326/ANNALS-24-02841 Dr. Maura Marcucci et al.
Points
- The POISE-3 trial compared hypotension-avoidance and hypertension-avoidance strategies in 2,603 older adults undergoing non-cardiac surgery to evaluate the effects on neurocognitive outcomes.
- Delirium incidence within three days post-surgery was similar, affecting 7.3 percent in the hypotension group and 7.0 percent in the hypertension group with no significant difference.
- Cognitive decline after one year occurred in 37.2 percent of the hypotension-avoidance group and 33.1 percent of the hypertension-avoidance group, also showing no statistically significant difference.
- Fewer patients in the hypotension-avoidance group required blood pressure intervention during surgery compared to the hypertension-avoidance group, indicating better intraoperative hemodynamic stability.
- These results support individualized blood pressure management strategies during surgery, as neither approach increased the risk of delirium or long-term cognitive decline.
Summary
This randomized controlled trial, part of the POISE-3 study, compared two blood pressure management strategies—hypotension-avoidance and hypertension-avoidance—in older adults undergoing non-cardiac surgery. On average, 2,603 patients aged 70 and considered at high vascular risk were randomly assigned to either strategy across 54 centers in 19 countries. The hypotension-avoidance strategy targeted a higher intraoperative mean arterial pressure (MAP) of 80 mm Hg or greater, while the hypertension-avoidance strategy aimed for a 60 mm Hg or greater MAP. In both groups, blood pressure medication management was adjusted according to the strategy, with renin-angiotensin system inhibitors withheld in the hypotension group and all medications continued in the hypertension group.
Results showed no significant difference between the two strategies in either delirium incidence during the first three days after surgery or in cognitive decline one year later. Specifically, 7.3% of the hypotension-avoidance group and 7.0% of the hypertension-avoidance group experienced delirium (relative risk [RR] 1.04; 95% CI, 0.79 to 1.38). For cognitive decline, 37.2% of patients in the hypotension-avoidance group and 33.1% in the hypertension-avoidance group experienced a decline of 2 or more points on the Montreal Cognitive Assessment (RR 1.13; 95% CI, 0.92 to 1.38). Furthermore, 19% of patients in the hypotension-avoidance group required intervention for hypotension, compared to 27% in the hypertension-avoidance group (RR 0.63; 95% CI, 0.52 to 0.76).
This study suggests that both blood pressure management strategies have similar outcomes regarding neurocognitive complications, providing flexibility for clinicians to tailor care. Given the lack of significant differences in patient outcomes, either strategy can be used safely without increasing the risk of post-surgical cognitive decline or delirium. These findings offer reassurance for clinicians and patients, emphasizing that managing blood pressure during surgery can be individualized without compromising cognitive health.
Link to the article: https://www.thelancet.com/journals/laneur/article/PIIS1474-4422(25)00154-1/abstract
References Marcucci, M., Chan, M. T. V., Painter, T. W., Efremov, S., Aguado, H. J., Astrakov, S. V., Kleinlugtenbelt, Y. V., Patel, A., Cata, J. P., Amir, M., Kirov, M., Leslie, K., Duceppe, E., Borges, F. K., De Nadal, M., Tandon, V., Landoni, G., Likhvantsev, V. V., Lomivorotov, V., … Harris, L. (2025). Effects of a hypotension-avoidance versus a hypertension-avoidance strategy on neurocognitive outcomes after noncardiac surgery. Annals of Internal Medicine, ANNALS-24-02841. https://doi.org/10.7326/ANNALS-24-02841
