Effect of Remimazolam on Hemodynamic Stability in Patients Undergoing Cardiac Surgery: A Grade-Assessed Systematic Review and Meta-Analysis of Randomized Controlled Trials

Hemodynamic instability during cardiac surgery, particularly procedures requiring cardiopulmonary bypass, increases the risk of mortality and adverse events. Conventional anesthetics such as propofol and etomidate have limitations in maintaining stability, prompting investigation of remimazolam, an ultra-short-acting benzodiazepine with a potentially favorable cardiovascular profile. This systematic review and meta-analysis evaluated the effects of remimazolam versus conventional anesthetics on hemodynamic stability, vasopressor use, extubation time, and recovery in cardiac surgery. Seven randomized controlled trials involving 557 patients were included following literature searches in PubMed, Scopus, and Cochrane Central Register of Controlled Trials. Data extraction and risk-of-bias assessment were conducted using the Cochrane RoB 2 tool, and certainty of evidence was graded with the Grading of Recommendations Assessment, Development, and Evaluation approach. Pooled analysis showed no significant differences in operative time (mean difference: 1.91 minutes, P = 0.53) or mean arterial pressure (mean difference: -0.90 mm Hg, P = 0.80). The risk of intraoperative hypotension was higher but not statistically significant with remimazolam (risk ratios: 1.25, P = 0.57); however, sensitivity analysis excluding one study demonstrated a significant 64% increase in hypotension risk (risk ratios: 1.64, P = 0.005), suggesting possible hemodynamic vulnerability. Remimazolam significantly shortened extubation time by 27.98 minutes (P = 0.04), while hospital stay, vasopressor use, and postoperative nausea and vomiting showed no significant differences. Overall, remimazolam did not significantly improve intraoperative hemodynamic stability compared with conventional anesthetics, but its main potential advantage may lie in enhancing recovery through faster extubation. The clinical importance of this finding remains uncertain, and remimazolam should not currently be regarded as superior for stability in cardiac anesthesia. Large, standardized randomized controlled trials are required to further define its safety and efficacy in cardiac surgery.