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Hypertension is most common medical reason for postponing surgery.How important is peri-operative hypertension?Hypertensive comorbidities associated with adverse perioperative outcomes .New Guidelines for managing patients with high blood pressure before surgery
Consequences of anesthesia on blood pressure regulation.
Prof. of Cardiology
Hypertension occuring in the pre-operative,
intra-operative or post-operative period.
What is meant by peri-operative?
Peri-operative generally refers to the three
phases of surgery: pre-operative, intra-
operative, and post-operative.
Hypertension is most common medical reason for postponing surgery
Peri-operative hypertensives are very very common
How important is peri-operative hypertension?
The effect of chronic hypertension on perioperative risk is determined
primarily by the presence of target organ damage , that is, coronary artery
disease, stroke, heart failure, and renal failure, all of which are known to
affect perioperative morbidity and mortality .
It is not clear if increased BP has an independent effect.
Target organ damage associated with hypertensive disease and total
cardiovascular risk, rather than high BP per se appear to determine
associated with adverse
include occult CAD(Q waves
on the ECG),heart failure, LVH,
serum creatinine higher than
2.0 mg/dL, and
Laryngoscopy & intubation are known causes of hypertension( Sympathetic activation )
Consequences of anesthesia on blood pressure regulation.
Blood pressure is a compromise between cardiac output and systemic vascular tone. Blood pressure regulation depends therefore on
heart rate (HR), left ventricle stroke volume (LVSV) and vascular resistance. The sympathetic nervous system is the main regulatory
system, which is blunted by anesthesia (general, or medullary). Fortunately, the backup systems, renin angotensin system and
vasopressin, can compensate the sympathetic nervous system impairment. Colson and Gaudard. J Hypertens Manag 2016, 2:013
To operate or not to operate,
that is the question.
When assessing patients for anaesthesia who
have elevated blood pressure, a number of
questions must be answered.
Is the patient known to be hypertensive on a previous
Are they on antihypertensive medication?
Does the patient have a treatable cause for their
Does the blood pressure control need alteration before
Does the patient have “white coat” hypertension?
Therefore, it may be helpful in some cases to contact the
referring physician in order to obtain more accurate arterial
pressure values than the ones measured at hospital
admission (white coat HTN).
Increased complications including myocardial
infarction , myocardial ischemia, dysrhythmias,
cerebrovascular events , and renal failure have
been reported if the preoperative diastolic blood
pressure is 110 mmHg or higher .
The patients with preoperative isolated systolic
hypertension(where the pressure is greater than
180 mmHg or the pulse pressure is greater than
80 mmHg) had a 40% increase in perioperative
Common reasons for delayed surgery
in patients with hypertension
Poorly controlled blood pressure of grade 3 according to ESC (systolic blood
pressure ≥ 180 mmHg and/or diastolic blood pressure ≥ 110 mmHg)
Discovery of end-organ damage that has not previously been evaluated or
Suspicion of secondary hypertension without properly documented aetiology
There are no randomized clinical trial data
showing what the optimal blood pressure
should be at the time of surgery.
New Guidelines for managing patients with high blood pressure before surgery
The Association of
Anaesthetists of Great Britain
and Ireland (AAGBI)
Why was this guideline developed?
This guideline aims to prevent the diagnosis of hypertension
being the reason that planned surgery is cancelled or delayed.
more focused on
with the long-
term reduction in
rates of CVD,
Primary care blood pressure assessment of patients before referral for elective surgery.
Secondary care blood pressure assessment of patients after referral for elective surgery.
Patients who present to pre-operative assessment
clinics without documented primary care blood
pressures should proceed to elective surgery if
clinic blood pressures are below 180 mmHg
systolic and 110 mmHg diastolic
The latest 2014 ACC/AHA Perioperative Guidelines do
not mention hypertension.
The 2007 version stated, “Numerous studies have shown
that stage 1 or stage 2 hypertension (systolic blood
pressure below 180 mm Hg and diastolic blood pressure
below 110 mm Hg) is not an independent risk factor for
perioperative cardiovascular complication
Recommendations on peri-operative hypertension
In patients with grade 1
or 2 hypertension (systolic
blood pressure ˂ 180
mmHg; diastolic blood
pressure ˂ 110 mmHg),
there is no evidence of
benefit from delaying
surgery to optimize
therapy. In such cases,
medications should be
continued during the
Preoperative antihypertensive medications
Most antihypertensive drugs should be continued to the day of surgery and restart as
soon as possible (when the patient will be able to swallow). Only agents that affect the
RAS should be cancelled — ACEIs and ARBs
The physical status of patients ≥ 3 according to American Association
of Anesthesiologists is a more significant predictor of aggressive
hypotension than receiving antihypertensive medication.
The American Society of Anaesthesiology classification of physical status(ASA)
d Treatment should ideally be
initiated between 30 days and (at
least) 2 days before surgery, starting
at a low dose, and should be
The target is a resting heart rate 60–
70 bpm, and systolic blood pressure
>100 mm Hg.
Perioperative use of beta-blockers may benefit only
patients at highest risk and may harm other patients.
Among perioperative complications, acute postoperative
hypertension (APH) is the most frequent one.
If it is left untreated, the APH is a major risk factor for adverse events
such as postoperative bleeding, cerebrovascular damage, myocardial
ischemia , arrhythmias, myocardial failure with congestive
pulmonary edema , breakup of vascular anastomoses.
The APH that occurs is
manifested in the first
20 minutes of the
and lasts an average of
Parenteral antihypertensive agents for treatment of perioperative hypertension
Abbreviation: CI, continuous infusion.
To solve an APH, several pharmacological solutions turned out to be efficient.
Preoperative Intraoperative Postoperative
SAP ≤ 180 mmHg,
MAP not lower
than 25–30% of
Resume antihypertensive drugs upon oral
intake or substitute i.v.
ECG, serum creatinine,
search for target organ
damage (heart, brain,
use laryngeal mask)
Measure blood pressure every 5–15 min
first hour then every 30 min until 3 h
continue day of surgery:
stop day of surgery:
diuretics, ACEI, ARB
Consider use of
Treat postoperative hypertension to MAP >
100 and <130 mmHg and HR 50 bpm;
Metoprolol: repeat 2–5 mg bolus i.v.;
labetolol: repeat 10–20 mg bolus i.v.;
nicardipine: 0.5–1 ug/kg/min i.v.;
nitroglycerine: 0.1–5 ug/kg/min i.v.
Recommendations for the perioperative management of
patients with hypertensive disease (opinion based)
Current Opinion in Anaesthesiology. 29(3):397-402, JUN 2016