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Background  The alpha-adrenergic agonist phenylephrine is often used to treat hypotension during anesthesia. In clinical situations, low blood pressure may require prompt intervention by intravenous bolus or infusion. Differences in responsiveness to phenylephrine treatment are commonly observed in clinical practice. Candidate gene studies indicate genetic variants may contribute to this variable response.    Methods  Pharmacological and physiological data were retrospectively extracted from routine clinical anesthetic records. Response to phenylephrine boluses could not be reliably assessed, so infusion rates were used for analysis. Unsupervised  k -means clustering was conducted on clean data containing 4130 patients based on phenylephrine infusion rate and blood pressure parameters, to identify potential phenotypic subtypes. Genome-wide association studies (GWAS) were performed against average infusion rates in two cohorts: phase I ( n  = 1205) and phase II ( n  = 329). Top genetic variants identified from the meta-analysis were further examined to see if they could differentiate subgroups identified by  k -means clustering.    Results  Three subgroups of patients with different response to phenylephrine were clustered and characterized: resistant (high infusion rate yet low mean systolic blood pressure (SBP)), intermediate (low infusion rate and low SBP), and sensitive (low infusion rate with high SBP). Differences among clusters were tabulated to assess for possible confounding influences. Comorbidity hierarchical clustering showed the resistant group had a higher prevalence of confounding factors than the intermediate and sensitive groups although overall prevalence is below 6%. Three loci with  P  < 1 × 10 −6  were associated with phenylephrine infusion rate. Only rs11572377 with  P  = 6.09 × 10 −7 , a 3′UTR variant of  EDN2 , encoding a secretory vasoconstricting peptide, could significantly differentiate resistant from sensitive groups ( P  = 0.015 and 0.018 for phase I and phase II) or resistant from pooled sensitive and intermediate groups ( P  = 0.047 and 0.018).    Conclusions  Retrospective analysis of electronic anesthetic records data coupled with the genetic data identified genetic variants contributing to variable sensitivity to phenylephrine infusion during anesthesia. Although the identified top gene,  EDN2 , has robust biological relevance to vasoconstriction by binding to endothelin type A (ET A ) receptors on arterial smooth muscle cells, further functional as well as replication studies are necessary to confirm this association.    Electronic supplementary material  The online version of this article (10.1186/s12916-019-1405-7) contains supplementary material, which is available to authorized users.

Dissecting genetic factors affecting phenylephrine infusion rates during anesthesia: a genome-wide association study employing EHR data