Hemodynamic and Perioperative Effects of Remimazolam Versus Propofol in Adult Cardiac Surgery: A Grade-Assessed...

Hemodynamic instability during adult cardiac surgery increases perioperative risk. Propofol is widely used but may cause dose-dependent hypotension and myocardial depression. Remimazolam, an ultra-short-acting benzodiazepine, has emerged as a potentially more hemodynamically stable alternative, although evidence in cardiac surgery remains limited. A PRISMA-compliant systematic review and meta-analysis were conducted to compare remimazolam with propofol in adult cardiac surgery. PubMed, Embase, Web of Science, and Scopus were searched from inception to January 2026. Randomized controlled trials (RCTs) and comparative cohort studies were included. Primary outcomes included study-defined hypotensive events, mean arterial pressure, heart rate, bispectral index, and operative time. Random-effects models were used for pooled analyses, and evidence certainty was assessed using the GRADE approach. Nine studies involving 903 patients were included. Compared with propofol, remimazolam significantly reduced the incidence of intraoperative hypotensive events (risk ratio 0.50, 95% confidence interval 0.31-0.80) with minimal heterogeneity. Mean arterial pressure and heart rate were comparable between groups. Remimazolam was associated with faster emergence, including shorter times to eye opening and extubation, while operative time, anesthetic depth, postoperative nausea and vomiting, delirium, and hospital stay showed no significant differences. Postoperative adverse events were reduced with remimazolam. Evidence certainty ranged from high to low, mainly due to heterogeneity and imprecision. Remimazolam may provide superior hemodynamic stability and faster postoperative recovery compared with propofol in adult cardiac surgery without compromising anesthetic efficacy or safety. Larger multicenter trials are needed to confirm these findings and define their long-term clinical benefits.