Publication date: Jun 03, 2025

Perioperative hemodynamic abnormalities have been associated with neurocognitive outcomes after noncardiac surgery. To compare the effects of perioperative hypotension-avoidance versus hypertension-avoidance strategies on delirium and 1-year cognitive decline after noncardiac surgery. Randomized controlled trial. (ClinicalTrials. gov: NCT03505723). 54 centers, 19 countries. 2603 high-vascular-risk patients undergoing noncardiac surgery, receiving 1 or more chronic antihypertensive medications (mean age, 70 years). 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. 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). 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. The COVID-19 pandemic challenged site participation in the substudy; although large, the sample size was lower than expected. There was no evidence of a difference in neurocognitive outcomes between the hypotension-avoidance and hypertension-avoidance strategies. Canadian Institutes of Health Research, Canada; National Health and Medical Research Council, Australia; Research Grant Council, Hong Kong SAR, China.

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