PURPOSE: Blood pressure (BP) fluctuations in patients undergoing valve surgery are common and BP management can be challenging. The Evaluation of Clevidipine in the Postoperative Treatment of Hypertension Assessing Safety Events (ECLIPSE) trial revealed that BP control was a significant predictor of increased 30-day mortality and renal dysfunction in patients undergoing cardiac surgery. The purpose of this analysis was to determine whether systolic BP (SBP) fluctuations outside of a prespecified range predict short-term mortality in valvular surgery patients.
METHODS: Of the 1,507 patients in ECLIPSE, the 342 who underwent valve surgery (repair/replacement, with/without coronary artery bypass graft [CABG]) were the focus of this analysis. BP control was assessed using area under the curve (AUC), capturing magnitude and duration of SBP excursions outside defined BP ranges. Patients were randomized 1:1 to clevidipine, a rapid-acting IV dihydropyridine calcium channel blocker, or a comparator (nitroglycerin, sodium nitroprusside, or nicardipine). Multiple logistic regression was used to estimate risk for AUC values related to 30-day mortality.
RESULTS: Baseline demographics were: mean age 66±12 years; male 63%; mean BP 137/69 mmHg; aortic valve surgery, n=231; mitral valve surgery, n=87; tricuspid valve surgery, n=2; and combined CABG+valve surgery, n=22. All patients had perioperative hypertension and were treated with IV agents. BP excursions outside the defined AUC range were a significant predictor of 30-day mortality, as was SBP at baseline. When the SBP range was narrowed (to 105–145 mmHg), reduction in BP fluctuations continued to have a salutary influence on preventing 30-day mortality. Although no statistically significant differences among antihypertensive agents existed in this population, a trend for improved BP control (AUC) with clevidipine versus active comparators was observed.
CONCLUSION: BP fluctuations were a powerful predictor of short-term mortality in patients undergoing cardiac valve surgery. Minimizing SBP fluctuations within a narrow range further improved 30-day mortality.
CLINICAL IMPLICATIONS: Tight perioperative BP control is critical. Short-acting BP medications that maintain patients within a narrow BP range may be beneficial during valve surgery.
DISCLOSURE: Cornelius Dyke, Consultant fee, speaker bureau, advisory committee, etc. The Medicines Company, Schering-Plough, Sanofi-Avenits, Bristol-Myers Squibb; No Product/Research Disclosure Information