Clinical Interpretation of Markedly Elevated First Intraoperative Systolic Blood Pressure in Non‐Cardiac Surgery

Dear Editor: We read with interest the recent article by Zhou et al. [1] investigating the association between the first systolic blood pressure measured in the operating room (first-OR-SBP) and perioperative ischemic stroke in non-brain, non-cardiac surgery. Using a large single-center retrospective cohort, the authors propose a threshold of 186 mm Hg as independently associated with perioperative ischemic stroke. While the sample size and analytic rigor are notable, several methodological and interpretative issues warrant further discussion. A primary concern relates to the reliance on a single, non-invasive blood pressure measurement obtained immediately after operating room arrival. This value is likely influenced by situational stress, anxiety, pain, and white-coat effects, which may not accurately reflect a patient's true hemodynamic burden. Prior literature suggests that perioperative risk is more closely related to sustained hypertension and blood pressure trajectories rather than isolated readings, raising the possibility of exposure misclassification in the current analysis [2]. The use of the minimum p-value approach to define the 186 mm Hg cutoff also deserves caution. Although statistically appealing, this data-driven method increases the risk of overfitting and may yield thresholds that lack external validity. Existing perioperative and hypertension guidelines generally recommend postponing elective surgery at systolic pressures above 180 mm Hg, and the incremental clinical relevance of a 186 mm Hg threshold over established cut points remains uncertain [3]. Residual confounding is another important limitation. Despite extensive multivariable adjustment and propensity score matching, unmeasured factors such as perioperative blood pressure variability, depth of anesthesia, timing and intensity of antihypertensive therapy, and postoperative blood pressure management were not fully accounted for. Blood pressure variability, in particular, has been consistently linked to cerebrovascular risk and may represent a stronger mechanistic contributor than a single pre-incision measurement [4]. Finally, the low observed incidence of perioperative ischemic stroke and the lack of systematic post-discharge neurological follow-up may have led to outcome under-ascertainment, especially for transient or clinically silent events. While the study generates a hypothesis that extreme first-OR-SBP may identify a high-risk subgroup, prospective multicenter studies incorporating repeated blood pressure measurements and standardized neurological surveillance are needed before this threshold can be translated into clinical decision-making [5]. Sincerely, All of the authors contributed planning, writing, and revision. The authors have nothing to report. The authors declare no conflicts of interest. No new data was generated or analyzed in support of this letter to the editor.