Targeted Intraoperative BP Control Shows No Functional Benefit During Noncardiac Surgery: JAMA
Netherlands: Researchers have found in a new study that stratifying mean arterial pressure (MAP) goals by hypotension risk during noncardiac surgery did not improve functional disability outcomes at 6 months compared with standard intraoperative blood pressure management.
The findings are from the PRETREAT Randomized Clinical Trial, published in JAMA by Matthijs Kant from the Department of Anaesthesiology, University Medical Center Utrecht, the Netherlands, and colleagues. The study explored whether proactively adjusting blood pressure targets based on patients’ risk of intraoperative hypotension could yield better postoperative recovery compared to conventional management.
Intraoperative hypotension — a common concern during surgery — is known to be linked to postoperative complications and poor outcomes. However, it remains uncertain whether a proactive approach to maintaining higher MAP levels can improve long-term recovery and functional capacity.
The PRETREAT trial enrolled 3,247 adults undergoing elective noncardiac surgery at two tertiary hospitals in the Netherlands between June 2021 and February 2024. Participants were randomly assigned to one of two groups: a proactive management group, where blood pressure targets were individualized based on preoperative risk of intraoperative hypotension (≥70 mm Hg for low risk, ≥80 mm Hg for intermediate risk, and ≥90 mm Hg for high risk), and a standard care group, where anesthesiologists managed blood pressure at their discretion, typically avoiding MAP levels below 65 mm Hg.
The study’s primary outcome was functional disability six months after surgery, measured using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0), which ranges from 0 (no disability) to 100 (complete disability). A difference of at least five points was considered clinically meaningful.
Key Takeaways:
- The trial was stopped early for futility after enrolling 3,247 of the planned 5,000 participants.
- The median age of participants was 59 years.
- Women comprised 53.5% of the study population.
- Participants were categorized by risk of intraoperative hypotension: 21% low risk, 56% intermediate risk, and 23% high risk.
- Baseline disability scores were similar between the proactive and standard care groups.
- At six months, the mean WHODAS score was 17.7 in the proactive group and 18.2 in the standard care group.
- The mean difference in WHODAS scores between the groups was –0.5 points, not statistically or clinically significant.
- None of the 23 secondary outcomes, including postoperative complications, quality of life, or mortality, showed meaningful differences between the two groups.
The researchers noted several limitations, including the use of preoperative rather than intraoperative risk assessment for MAP targets, potential attrition bias due to missing data in nearly 29% of patients, and the lack of blinding among anesthesiologists in the proactive group. Additionally, postoperative hypotension was not specifically addressed, and the study’s early termination reduced statistical power for subgroup analyses.
Overall, the trial concluded that proactive, risk-based intraoperative blood pressure management does not provide added benefit over standard care in improving long-term functional outcomes after noncardiac surgery. The results highlight that maintaining a MAP of at least 65 mm Hg, as typically practiced, remains an effective and practical approach for most patients.
The study highlights the importance of individualized but pragmatic blood pressure management during surgery and calls for further research to better understand how intraoperative hemodynamic strategies influence long-term recovery and organ protection.
Reference:
Kant M, van Klei WA, Hollmann MW, et al. Proactive vs Reactive Treatment of Hypotension During Surgery: The PRETREAT Randomized Clinical Trial. JAMA. Published online October 12, 2025. doi:10.1001/jama.2025.18007
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