Perioperative Hemodynamic Management in Elderly Hypertensive Patients: A Systematic Review of Monitoring-Guided Strategies and Postoperative Outcomes

Background Older adults receiving long-term antihypertensive therapy represent a rapidly growing surgical population in whom intraoperative blood pressure management remains contentious. Observational evidence consistently links intraoperative hypotension with adverse postoperative outcomes, but whether specific blood pressure targets or hemodynamic management strategies improve clinical outcomes remains uncertain Methods We searched PubMed/MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, Web of Science, and ClinicalTrials.gov from 1 January 2013 to 15 January 2026 for randomized controlled trials (RCTs) and prospective or retrospective cohort studies of haemodynamic monitoring-guided management in patients with a mean or median age of at least 65 years receiving chronic antihypertensive therapy or with documented chronic hypertension undergoing non-cardiac surgery. Two reviewers independently screened records, extracted data using a piloted form capturing design, setting, population, hypertension status, intervention, comparator, and raw outcome events, and assessed risk of bias (RoB 2 for RCTs; ROBINS-I for cohort studies). Quantitative pooling was prespecified only for comparisons with three or more studies sharing design, intervention class, and outcome definition; otherwise, a structured narrative synthesis with fully tabulated study-level effect data was performed. Certainty was rated with GRADE. Reporting follows PRISMA 2020. Results Nineteen studies (7 randomized controlled trials reported in 9 publications; 12 cohort studies) comprising 1,074,313 patients were included. In RCTs, higher or individualized intraoperative blood pressure targets did not reduce major vascular or organ-injury composites compared with routine targets (POISE-3: risk ratio [RR] 0.99, 95% CI 0.89–1.11; IMPROVE-multi: RR 1.10, 95% CI 0.93–1.30), although one small trial favoured individualized systolic targets (INPRESS: RR 0.74, 95% CI 0.57–0.95); certainty was low because of inconsistency and indirectness. Observational cohorts consistently reported duration-dependent associations between intraoperative hypotension and acute kidney injury or myocardial injury (moderate certainty for the association, not for a causal effect of any specific target). Goal-directed haemodynamic therapy was neutral in the largest contemporary trial (OPTIMISE II: postoperative infection RR 1.02, 95% CI 0.88–1.18) but beneficial in smaller earlier trials (low certainty). Continuing renin–angiotensin-system inhibitors increased intraoperative hypotension (RR 1.31, 95% CI 1.19–1.44) without increasing major complications (RR 1.02, 95% CI 0.87–1.19; moderate certainty). A hypotension-avoidance strategy did not reduce postoperative delirium in randomized data (cogPOISE-3: RR 1.04, 95% CI 0.79–1.38), and observational findings were inconsistent (low certainty). Conclusions Intraoperative hypotension is consistently and duration-dependently associated with organ injury in observational surgical cohorts, although much of this evidence is derived from broader non-cardiac surgical populations rather than exclusively elderly hypertensive patients. Randomized evidence specific to elderly hypertensive populations remains limited and does not demonstrate consistent benefit from higher blood pressure targets, goal-directed haemodynamic therapy, or specific antihypertensive withholding strategies.Recommendations for this population should rest on guidelines and individualized judgment rather than on claims of moderate-certainty trial evidence that the current literature does not provide. Renal denervation and other device-based therapies are outside the scope of this review and are identified as future research priorities only.