Does managing blood pressure differently during surgery affect memory loss?

No. The POISE-3 trial found that both hypotension-avoidance and hypertension-avoidance strategies result in similar rates of postoperative delirium and cognitive decline at one year.

What blood pressure targets were tested in the study?

The study compared two mean arterial pressure (MAP) targets during surgery: 80 mm Hg for hypotension-avoidance and 60 mm Hg for hypertension-avoidance.

Should blood pressure medications be paused before non-cardiac surgery?

In the hypotension-avoidance strategy, renin–angiotensin system inhibitors were paused on the day of surgery, but this approach was found to be just as safe as continuing all medications.

Is one blood pressure strategy better for brain health after surgery?

No. Both approaches led to similar neurocognitive outcomes, suggesting that doctors can individualize care without increasing brain-related surgical risks.

Study: Blood Pressure Strategy During Surgery Doesn’t Affect Brain Health

A major international clinical trial published in the Annals of Internal Medicine has confirmed that managing either low or high blood pressure during non-cardiac surgery results in similar neurocognitive outcomes.

The findings suggest that clinicians can choose either a hypotension-avoidance or hypertension-avoidance strategy without increasing the risk of postoperative delirium or long-term cognitive decline.

This landmark study provides reassuring evidence for both physicians and patients, especially older adults with vascular risk undergoing surgery while on chronic blood pressure medications.

Key Study Highlights

The trial included 2,603 patients from 54 centers in 19 countries, making it the largest trial to date on perioperative blood pressure and cognition.
Participants were 70 years old on average, taking at least one antihypertensive drug, and classified as high-risk for vascular complications.
Two intraoperative MAP (mean arterial pressure) strategies were compared:
- Hypotension-avoidance strategy: Target MAP ≥80 mm Hg, with certain medications paused perioperatively.
- Hypertension-avoidance strategy: Target MAP ≥60 mm Hg, with continuation of all blood pressure medications.
The study found no significant differences in short-term delirium or one-year cognitive decline between the two groups.
Findings support greater physician flexibility when managing chronic medications and intraoperative pressure goals in older adults.

Contents

Study Context: Blood Pressure Targets in Non-Cardiac Surgery

Maintaining stable blood pressure during surgery is critical, particularly in older adults with cardiovascular risk factors.

For patients on chronic antihypertensive medications, the management of mean arterial pressure (MAP) during surgery can influence outcomes ranging from organ function to brain health.

The POISE-3 substudy explored whether aiming to avoid low blood pressure (hypotension) or high blood pressure (hypertension) would lead to different neurological or cognitive outcomes.

Study Design and Blood Pressure Strategies

Participants were randomized into two intervention arms during non-cardiac surgery:

Hypotension-avoidance strategy:
- Targeted a MAP ≥80 mm Hg.
- Paused renin–angiotensin system (RAS) inhibitors on surgery day and for two days post-op.
- Continued other antihypertensive medications only if patient BP permitted.
Hypertension-avoidance strategy:
- Targeted a MAP ≥60 mm Hg.
- Continued all chronic blood pressure medications, including RAS inhibitors.

This approach aimed to test how differing perioperative blood pressure protocols influence postoperative delirium and long-term cognitive function.

Outcomes: No Difference in Delirium or Cognitive Decline

Researchers found no statistically significant difference between the two strategies in the rate of delirium within three days of surgery.

There was also no difference in cognitive decline at one year, as measured by validated neurocognitive assessments.

The likely explanation is that although the two strategies produced measurable variations in blood pressure, these were not substantial or sustained enough to impact brain outcomes.

Clinical Implications for Physicians and Surgical Teams

Dr. Maura Marcucci, principal investigator from McMaster University and PHRI, emphasized that these results offer clinical flexibility.

“This study shows that either approach can be used safely without raising the risk of memory loss or confusion,” she explained.

These findings are especially relevant for surgical teams managing patients whose blood pressure is typically managed by cardiologists or primary care providers.

The trial also resolves long-standing uncertainty about whether modifying antihypertensive protocols perioperatively affects cognitive health in elderly patients.

Reassurance for Patients and Families

Cognitive side effects like delirium and memory loss are some of the most feared complications of surgery in older adults.

This study provides peace of mind that either blood pressure management approach is safe for brain health.

For the millions of people on antihypertensive medications who undergo surgery every year, this evidence helps clarify what to expect and how to manage chronic treatments pre- and post-op.

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