Maura Marcucci, Matthew T V Chan, Thomas W Painter, Sergey Efremov, Hector J Aguado, Sergey V Astrakov, Ydo V Kleinlugtenbelt, Ameen Patel, Juan P Cata, Mohammed Amir, Mikhail Kirov, Kate Leslie, Emmanuelle Duceppe, Flavia K Borges, Miriam de Nadal, Vikas Tandon, Giovanni Landoni, Valery V Likhvantsev, Vladimir Lomivorotov, Daniel I Sessler, María José Martínez-Zapata, Denis Xavier, Edith Fleischmann, Chew Yin Wang, Christian S Meyhoff, Maria Wittmann, David Torres, David Highton, Michael Jacka, Vishwanath B, Kelly Zarnke, Ravinder Singh Sidhu, Giorgio Oriani, Sabry Ayad, Steven Minear, Tristan E Weaver, Kurt Ruetzler, Claudia Brusasco, Joel L Parlow, Elizabeth Maxwell, Scott Miller, Marko Mrkobrada, Keyur Suresh Chandra Bhatt, Prashant Rahate, Ana Kowark, Giuseppe De Blasio, Sandra N Ofori, David Conen, Sadeesh Srinathan, Wojciech Szczeklik, Raja Jayaram, Richard K Ellerkmann, Mona Momeni, Ingrid Copland, Jessica Vincent, Kumar Balasubramanian, Zhuoru Li, Michael Ke Wang, Deyang Li, Michael H McGillion, Andrea Kurz, Mukul Sharma, Timothy G Short, P J Devereaux
{"title":"避免低血压与避免高血压策略对非心脏手术后神经认知结果的影响。","authors":"Maura Marcucci, Matthew T V Chan, Thomas W Painter, Sergey Efremov, Hector J Aguado, Sergey V Astrakov, Ydo V Kleinlugtenbelt, Ameen Patel, Juan P Cata, Mohammed Amir, Mikhail Kirov, Kate Leslie, Emmanuelle Duceppe, Flavia K Borges, Miriam de Nadal, Vikas Tandon, Giovanni Landoni, Valery V Likhvantsev, Vladimir Lomivorotov, Daniel I Sessler, María José Martínez-Zapata, Denis Xavier, Edith Fleischmann, Chew Yin Wang, Christian S Meyhoff, Maria Wittmann, David Torres, David Highton, Michael Jacka, Vishwanath B, Kelly Zarnke, Ravinder Singh Sidhu, Giorgio Oriani, Sabry Ayad, Steven Minear, Tristan E Weaver, Kurt Ruetzler, Claudia Brusasco, Joel L Parlow, Elizabeth Maxwell, Scott Miller, Marko Mrkobrada, Keyur Suresh Chandra Bhatt, Prashant Rahate, Ana Kowark, Giuseppe De Blasio, Sandra N Ofori, David Conen, Sadeesh Srinathan, Wojciech Szczeklik, Raja Jayaram, Richard K Ellerkmann, Mona Momeni, Ingrid Copland, Jessica Vincent, Kumar Balasubramanian, Zhuoru Li, Michael Ke Wang, Deyang Li, Michael H McGillion, Andrea Kurz, Mukul Sharma, Timothy G Short, P J Devereaux","doi":"10.7326/ANNALS-24-02841","DOIUrl":null,"url":null,"abstract":"<p><strong>Background: </strong>Perioperative hemodynamic abnormalities have been associated with neurocognitive outcomes after noncardiac surgery.</p><p><strong>Objective: </strong>To compare the effects of perioperative hypotension-avoidance versus hypertension-avoidance strategies on delirium and 1-year cognitive decline after noncardiac surgery.</p><p><strong>Design: </strong>Randomized controlled trial. (ClinicalTrials.gov: NCT03505723).</p><p><strong>Setting: </strong>54 centers, 19 countries.</p><p><strong>Participants: </strong>2603 high-vascular-risk patients undergoing noncardiac surgery, receiving 1 or more chronic antihypertensive medications (mean age, 70 years).</p><p><strong>Intervention: </strong>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.</p><p><strong>Measurements: </strong>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).</p><p><strong>Results: </strong>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.</p><p><strong>Limitation: </strong>The COVID-19 pandemic challenged site participation in the substudy; although large, the sample size was lower than expected.</p><p><strong>Conclusion: </strong>There was no evidence of a difference in neurocognitive outcomes between the hypotension-avoidance and hypertension-avoidance strategies.</p><p><strong>Primary funding source: </strong>Canadian Institutes of Health Research, Canada; National Health and Medical Research Council, Australia; Research Grant Council, Hong Kong SAR, China.</p>","PeriodicalId":7932,"journal":{"name":"Annals of Internal Medicine","volume":" ","pages":"909-920"},"PeriodicalIF":19.6000,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":"{\"title\":\"Effects of a Hypotension-Avoidance Versus a Hypertension-Avoidance Strategy on Neurocognitive Outcomes After Noncardiac Surgery.\",\"authors\":\"Maura Marcucci, Matthew T V Chan, Thomas W Painter, Sergey Efremov, Hector J Aguado, Sergey V Astrakov, Ydo V Kleinlugtenbelt, Ameen Patel, Juan P Cata, Mohammed Amir, Mikhail Kirov, Kate Leslie, Emmanuelle Duceppe, Flavia K Borges, Miriam de Nadal, Vikas Tandon, Giovanni Landoni, Valery V Likhvantsev, Vladimir Lomivorotov, Daniel I Sessler, María José Martínez-Zapata, Denis Xavier, Edith Fleischmann, Chew Yin Wang, Christian S Meyhoff, Maria Wittmann, David Torres, David Highton, Michael Jacka, Vishwanath B, Kelly Zarnke, Ravinder Singh Sidhu, Giorgio Oriani, Sabry Ayad, Steven Minear, Tristan E Weaver, Kurt Ruetzler, Claudia Brusasco, Joel L Parlow, Elizabeth Maxwell, Scott Miller, Marko Mrkobrada, Keyur Suresh Chandra Bhatt, Prashant Rahate, Ana Kowark, Giuseppe De Blasio, Sandra N Ofori, David Conen, Sadeesh Srinathan, Wojciech Szczeklik, Raja Jayaram, Richard K Ellerkmann, Mona Momeni, Ingrid Copland, Jessica Vincent, Kumar Balasubramanian, Zhuoru Li, Michael Ke Wang, Deyang Li, Michael H McGillion, Andrea Kurz, Mukul Sharma, Timothy G Short, P J Devereaux\",\"doi\":\"10.7326/ANNALS-24-02841\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p><strong>Background: </strong>Perioperative hemodynamic abnormalities have been associated with neurocognitive outcomes after noncardiac surgery.</p><p><strong>Objective: </strong>To compare the effects of perioperative hypotension-avoidance versus hypertension-avoidance strategies on delirium and 1-year cognitive decline after noncardiac surgery.</p><p><strong>Design: </strong>Randomized controlled trial. 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引用次数: 0
摘要
背景：围手术期血流动力学异常与非心脏手术后的神经认知结果有关。目的：比较围手术期降压与降压策略对非心脏手术后谵妄和1年认知能力下降的影响。设计：随机对照试验。(ClinicalTrials.gov: NCT03505723)。地点：54个中心，19个国家。参与者：2603名接受非心脏手术、接受一种或多种慢性降压药物治疗的高危血管患者（平均年龄70岁）。干预：在降压避免策略中，术中平均动脉压（MAP）目标为80 mm Hg或更高；术前和术后2天，停用肾素-血管紧张素-醛固酮系统抑制剂，收缩压达到130 mm Hg或更高时，按照规定给予其他慢性降压药物。在高血压避免策略中，术中MAP目标为60 mm Hg或更高；所有慢性降压药物均在围手术期继续使用。测量：术后第1 - 3天谵妄（主要结局）；术后1年蒙特利尔认知评估（MoCA）与基线相比下降2分或以上（次要结局）。结果：低血压避免组1310例患者中有95例（7.3%）出现谵妄，高血压避免组1293例患者中有90例（7.0%）出现谵妄（相对危险度[RR]， 1.04 [95% CI, 0.79 ~ 1.38]）。在701例完成1年MoCA（全程或电话版本）的患者中，347例低血压避免组中有129例（37.2%），354例高血压避免组中有117例（33.1%）下降2点或以上（RR, 1.13 [CI， 0.92至1.38]）。降压避免组中有19%的患者和降压避免组中有27%的患者出现了需要干预的低血压（RR, 0.63 [CI， 0.52至0.76]），主要是在术中；两组患者术后仅有5%出现低血压。局限性：COVID-19大流行对子研究的现场参与提出了挑战；虽然样本量很大，但低于预期。结论：没有证据表明低血压避免和高血压避免策略在神经认知结果上有差异。主要资金来源：加拿大卫生研究所，加拿大；澳大利亚国家卫生和医学研究委员会；中国香港特别行政区研究资助局。
Effects of a Hypotension-Avoidance Versus a Hypertension-Avoidance Strategy on Neurocognitive Outcomes After Noncardiac Surgery.
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.
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.
期刊介绍：
Established in 1927 by the American College of Physicians (ACP), Annals of Internal Medicine is the premier internal medicine journal. Annals of Internal Medicine’s mission is to promote excellence in medicine, enable physicians and other health care professionals to be well informed members of the medical community and society, advance standards in the conduct and reporting of medical research, and contribute to improving the health of people worldwide. To achieve this mission, the journal publishes a wide variety of original research, review articles, practice guidelines, and commentary relevant to clinical practice, health care delivery, public health, health care policy, medical education, ethics, and research methodology. In addition, the journal publishes personal narratives that convey the feeling and the art of medicine.
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