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Surgical Management of Patients with Hypertension

Author: Mostafa Borahay, MBBS

Mentor: Daniel M. Breitkopf, MD
Editor: Sireesha Reddy, MD

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Approximately one in three adults in the United States has a diagnosis of systemic hypertension and almost half of them have uncontrolled blood pressure. Hypertension is the most common cause of morbidity and mortality worldwide. Hypertension is a risk factor for perioperative cardiovascular events including myocardial ischemia, infarction, and heart failure. Patients with uncontrolled hypertension are at risk for intraoperative exaggerated hemodynamic lability, in addition to exacerbation of pre-existing end organ damage. Induction of anesthesia triggers sympathetic activation that may raise systemic blood pressure (BP) by 20 to 30 mm Hg in normotensive patients and up to 90 mm Hg in untreated patients. Prolonged anesthesia can lower BP due to direct inhibition by anesthetics of sympathetic tone. Generally, well controlled hypertension is considered a minor risk factor and should not trigger postponement of surgery. Factors that may indicate the need to postpone surgery include systolic BP >180 mm Hg, diastolic BP >110 mm Hg, and untreated underlying or associated comorbidities.

Preoperative optimization includes evaluation and control of blood pressure. Evaluation should include determination of severity of hypertension, functional status, and assessment of other risk factors, such as diabetes, smoking, coronary artery disease, and target organ damage (e.g. left ventricular and/or renal dysfunction). Functional status is an important predictor of perioperative outcome and can guide further workup. It is often appropriate to proceed with surgery in highly functional asymptomatic patients without further cardiovascular testing. Cardiac studies such as pharmacologic stress testing can benefit patients with unknown or poor functional capacity. Poor functional capacity is defined as <4 metabolic equivalents (METs), consistent with inability to climb a flight of stairs.

In most situations, chronic oral antihypertensive therapy should be continued and taken on the morning of surgery with a sip of water. Abrupt cessation of beta blockers and clonidine can lead to rebound hypertension. In contrast, angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) can blunt renin activation and cause intraoperative hypotension. These agents should be omitted on the morning of surgery and restarted postoperatively as soon as feasible. Particular attention should be paid to hypokalemia in patients using diuretics. Historically, beta blockers were started preoperatively for cardioprotection; however, care should be exercised as some trials showed increased risk of hypotension, bradycardia, and stroke.

Intraoperatively, close cardiovascular monitoring is recommended, occasionally including the use of invasive techniques such as arterial lines. Excessive shifts in intravascular volume should be avoided by paying close attention to blood loss and fluid administration.

Postoperatively, hypertensive patients are prone to exaggerated hypertensive responses to stimuli such as pain and bladder distention. Continuation of antihypertensives, appropriate pain management, and close monitoring are important. Parenteral antihypertensives may be needed, particularly in hypertensive emergencies.


Further Reading:

Whelton PK, Carey RM, Aronow WS, et al; 2017  ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018 May 15;71(19):e127-e248. doi: 10.1016/j.jacc.2017.11.006. Epub 2017 Nov 13. Erratum in: J Am Coll Cardiol. 2018 May 15;71(19):2275-2279. PMID: 29146535.

Gala, R.; Chapter 39 Preoperative Considerations.  Williams Gynecology, 3e Eds. Barbara L. Hoffman, et al. New York, NY: McGraw-Hill, 2016. 

Stergiou GS, Palatini P, Parati G, et al; European Society of Hypertension Council and the European Society of Hypertension Working Group on Blood Pressure Monitoring and Cardiovascular Variability. 2021 European Society of Hypertension practice guidelines for office and out-of-office blood pressure measurement. J Hypertens. 2021 Jul 1;39(7):1293-1302. doi: 10.1097/HJH.0000000000002843. PMID: 33710173.

Initial Approval: November 2016; Reviewed May 2018. Revised November 2019. Revised July 2021. Minor Revision March 2023.

Originally titled “Surgical Management of Women with Hypertenstion”.  Renamed to current title March 2023.

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