Remimazolam provides better hemodynamic stability than propofol in hypertensive surgical patients: a randomized single-blinded trial.

PURPOSE: Hypertensive surgical patients face heightened perioperative cardiovascular risk, and propofol often induces hypotension. This trial aimed to compare remimazolam and propofol for hemodynamic stability in hypertensive patients undergoing non-cardiac surgery, and explore underlying cardiac and vascular mechanisms via continuous monitoring.

METHODS

This randomized single-blind trial enrolled 122 adults with controlled hypertension undergoing elective non-cardiac surgery, assigned to remimazolam-based or propofol-based total intravenous anesthesia. Primary outcomes were intraoperative hypotension episodes (mean arterial pressure < 65 mmHg or a > 20% decrease from baseline), norepinephrine bolus frequency and total dose. Hemodynamics were continuously tracked by Continuous Non-Invasive Arterial Pressure Monitor 500, with anesthesia depth maintained at a bispectral index of 40-60.

RESULTS

Baseline characteristics were comparable. The remimazolam group had fewer hypotension episodes (remimazolam group vs. propofol group, median episodes [interquartile range, IQR], 2 [0-3] vs. 3 [1-5]; p = 0.003), fewer norepinephrine boluses (1 [0-3] vs. 3 [1-5]; p = 0.001), and lower total dose (8 µg [0-24] vs. 24 µg [8-40]; p < 0.001). Remimazolam showed non-significant trends toward smaller reductions in cardiac output (CO, - 8.10% vs. - 13.10%, p = 0.35) and systemic vascular resistance (SVR, - 10.83% vs. - 14.91%, p = 0.46). Extubation time and post-anesthesia care unit stay were similar.

CONCLUSION

For hypertensive patients, remimazolam provides superior hemodynamic stability over propofol, evidenced by fewer hypotensive episodes, reduced norepinephrine requirements, and attenuated perturbations in CO and SVR, without delaying recovery. It represents a valuable anesthetic alternative for this high-risk cohort.