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

Summary

In hypertensive adults ≥60 years undergoing major abdominal surgery, targeting intraoperative MAP ≥80 mmHg (vs ≥65 mmHg) reduced the composite of 30‑day mortality or major organ dysfunction (RR 0.78) and decreased acute kidney injury. Effects were achieved under continuous hemodynamic monitoring and protocolized fluid therapy.

Key Findings

• Primary composite outcome (mortality or major organ dysfunction) was lower with MAP ≥80 vs ≥65 mmHg (38.1% vs 48.9%; RR 0.78; 95% CI 0.65–0.93; P=0.006).
• Acute kidney injury incidence was reduced in the higher-MAP group (23.5% vs 33.7%; P=0.005).
• Mean achieved intraoperative MAPs were 88±9 mmHg (treatment) vs 77±7 mmHg (control) under continuous monitoring and protocolized fluid therapy.

Clinical Implications

For hypertensive, high-risk patients undergoing major abdominal surgery, anesthesiologists should consider targeting MAP ≥80 mmHg with vigilant monitoring and protocolized fluids to reduce postoperative organ dysfunction, especially AKI.

Limitations

• Open-label design may introduce performance bias; blinding of MAP targets is not feasible.
• Generalizability limited to older, hypertensive patients undergoing major abdominal surgery; effect largely driven by reductions in mild-to-moderate AKI.

Future Directions

Evaluate optimal MAP targets across broader surgical populations (including non-hypertensive patients), explore individualized autoregulation-guided targets, and assess long-term renal and cardiovascular outcomes.