Intraoperative Hypotension and Myocardial Injury after Non-Cardiac Surgery

Abstract

Introduction: Intraoperative hypotension (IOH) is associated with myocardial injury after non-cardiac surgery (MINS). This review quantifies IOH thresholds and duration linked to MINS.
Methods: Systematic literature search (2015–2024) of large cohort studies and post-hoc analyses of RCTs defining IOH as MAP <65 mmHg or systolic BP <90 mmHg. Primary outcome: MINS (troponin elevation without ischemia symptoms).
Results: Seven studies (n=45,892) consistently showed IOH with MAP <65 mmHg for cumulative >10 minutes increased MINS risk (adjusted OR 1.3–2.4 per 10-min increment). MAP <55 mmHg for even 1 minute doubled risk (OR 2.0). Higher risk in patients with baseline cardiovascular disease.
Discussion: Autoregulatory failure occurs at MAP <65 mmHg, causing subendocardial ischemia. Avoidance of prolonged hypotension, not just absolute values, is key. Continuous noninvasive monitoring may help.
Conclusions: Intraoperative MAP should be maintained ≥65 mmHg, ideally ≥75 mmHg in high-risk patients. Duration of hypotension should be minimized using proactive vasopressors and fluid optimization.