The Goldilocks principle as it applies to perioperative blood pressure: what is too high, too low, or just right?

In this issue of the British Journal of Anaesthesia, Professor Venkatesan and colleagues,¹ using data from the large UK Clinical Practice Research Datalink (CPRD) database, found a significant association between low preoperative arterial blood pressure (BP) values and increased postoperative mortality, but only in an elderly population of patients. The risk thresholds started at a preoperative systolic BP of 119 mm Hg and diastolic BP of 63 mm Hg compared with a reference BP of 120 mm Hg. Elevated diastolic, but not systolic BP, was also associated with increased mortality in the entire cohort of patients. These BP readings are considered within the normal, in fact optimal, ranges of acceptable BP for long-term control. Readers should not be surprised that elevated BP was associated with adverse outcomes. However, the findings that only elevated diastolic readings, not systolic hypertension, and 'low' (though the adjective 'lower' would likely be more descriptive of the actual findings) BP are associated with mortality are novel findings. The findings regarding low BP add weight to a growing body of observational data suggesting intraoperative hypotension is associated with adverse outcome. This article challenges us to perhaps be as concerned about low BP readings as we are about elevated BP in the preoperative as well as intraoperative periods.

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