HIgh versus STAndard blood Pressure target in hypertensive high-risk patients undergoing elective major abdominal surgery: the HISTAP multicenter randomized clinical trial.

Summary

In 630 hypertensive high-risk adults undergoing major abdominal surgery, targeting intraoperative MAP ≥80 mmHg (vs ≥65 mmHg) reduced the composite of postoperative mortality and major organ dysfunction (RR 0.78) and decreased acute kidney injury. Benefits occurred under continuous hemodynamic monitoring and protocolized fluids.

Key Findings

• Primary composite outcome occurred in 38.1% (MAP≥80) vs 48.9% (MAP≥65); RR 0.78 (95% CI 0.65–0.93; P=0.006).
• Acute kidney injury was less frequent with MAP≥80 (23.5% vs 33.7%; P=0.005).
• Mean intraoperative MAP separation was achieved: 88±9 vs 77±7 mmHg.
• Trial pre-registered (NCT05637606); conducted at 18 centers with protocolized fluids and continuous monitoring.

Clinical Implications

For hypertensive high-risk patients undergoing major abdominal surgery, consider targeting MAP ≥80 mmHg with continuous monitoring and protocolized fluids to lower postoperative organ dysfunction, balancing vasopressor exposure and patient comorbidities.

Limitations

• Open-label hemodynamic targeting may introduce performance bias
• Population limited to hypertensive high-risk abdominal surgery; generalizability to other surgeries uncertain

Future Directions

Evaluate optimal MAP targets across broader surgical populations, assess long-term renal and cardiovascular outcomes, and define vasopressor strategies minimizing adverse effects.