Hemodynamic stability with remimazolam versus propofol during anesthesia induction in hypertensive patients: a meta-analysis with trial sequential analysis of randomized controlled trials

Background: Hypertensive patients tend to have an increased risk of hypotension during anesthesia induction, which can result in adverse outcomes. This study aimed to compare hemodynamic stability with remimazolam versus propofol in hypertensive patients. Methods: This meta-analysis analyzed randomized controlled trials investigating the hemodynamic parameters of remimazolam versus propofol during anesthesia induction in hypertensive adults. A systematic search of electronic databases was conducted in November 2024. Results: Six studies were included in the final analysis. The administration of remimazolam significantly lowered the risk of hypotension (risk ratio [RR] 0.711; 95% CI 0.545 to 0.929; I2 = 67.54%) and bradycardia (RR 0.256; 95% CI 0.101 to 0.649; I2 = 0.0%). It also resulted in a higher minimum mean arterial pressure (mean difference [MD] 9.023 mmHg; 95% CI 0.243 to 17.802; I² = 97.50%) and higher minimum heart rate (MD 7.200 beats/min; 95% CI 1.960 to 12.441; I² = 86.40%). Despite these findings, substantial heterogeneity was observed in continuous outcomes. The trial sequential analysis revealed that none of the outcomes reached the required information size. Conclusions: The administration of remimazolam showed a trend toward superior hemodynamic stability compared with propofol during anesthesia induction in hypertensive patients, especially in minimizing the incidence of hypotension and bradycardia. However, the trial sequential analysis results remain inconclusive, the current evidence is limited by small sample sizes, and larger trials are needed to confirm our findings.