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Surgical Management of Women with Hypertension

1/1/2017 - Mostafa Borahay, MBBS

Mentor: Daniel M. Breitkopf, MD

Editor: Abimbola O. Famuyide, MD

Approximately 1 in 3 US adults have a diagnosis of systemic hypertension, and almost half of them have uncontrolled blood pressure. 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 and inhibition of sympathetic tone. Generally, 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 mmHg, diastolic BP >110 mmHg, and non-treated 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 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. 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. Traditionally, beta blockers were started preoperatively for cardioprotection; however, care should be exercised as some trials showed increased risk of hypotension, bradycardia, and stroke. Patients on long-term beta blockers are usually advised to continue them.

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:

Fleisher LA et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;64:e77–137.

Gala RB (2016). Preoperative Considerations. In Williams Gynecology. 2nd ed. New York, N.Y.: McGraw-Hill Education LLC.

Initial Approval: 11/1/2016

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