The hidden myocardium: Why intraoperative hypotension should be treated as myocardial injury prevention rather than a transient anaesthetic variable

Intraoperative hypotension (IOH) has traditionally been regarded as a transient and largely reversible physiological disturbance inherent to the administration of general and regional anaesthesia. However, contemporary perioperative outcomes research consistently suggests that IOH behaves not as a binary, threshold-based phenomenon, but rather as a duration-dependent ischaemic exposure affecting vulnerable end-organs. This manuscript argues that IOH should be reframed as a perioperative type-2 ischaemic syndrome, rather than being treated merely as an expected haemodynamic variable that is easily corrected with fluid boluses or intermittent sympathomimetic administration. Rather than targeting historically derived universal mean arterial pressure (MAP) thresholds alone, perioperative teams should adopt a holistic myocardial-protection framework incorporating MAP, systolic pressure, diastolic pressure, pulse pressure, and markers of organ perfusion. This framework must be grounded in an understanding of the patient’s specific baseline perfusion pressure, an avoidance of cumulative hypotensive burden, and the judicious implementation of titrated vasopressor therapy alongside optimisation of preload, contractility, and tissue perfusion. This reconceptualisation has important implications for intraoperative anaesthetic management, postoperative biomarker surveillance, and the design of interdisciplinary, patient-centred perioperative care pathways.