This document discusses anesthesia considerations for patients with hypertension undergoing surgery. It notes that up to 13% of adult surgical patients have hypertension. Anesthesia can impact blood pressure through effects on the sympathetic nervous system and renin-angiotensin system. Careful blood pressure monitoring and management of antihypertensive drugs is important perioperatively to prevent hemodynamic instability. The anesthesiologist must consider the patient's hypertension severity and end-organ damage to appropriately titrate anesthesia and guide perioperative treatment and management.

1. Running Head: ANESTHESIA FOR PATIENTS WITH
HYPERTENSION 1
ANESTHESIA FOR PATIENTS WITH HYPERTENSION2
Anesthesia for patients with hypertension
Charnel N., Coleman
St. Petersburg College
Anesthesia for patients with hypertension
Essential hypertension has been found to be a common form of
pathology that is observed in adult patients who undergo
surgery. According to Le Manach et al. (2016), it was revealed
through a study that up to 13% of sampled adult patients
exhibited essential hypertension. Whereas, this study showed
essential hypertension and an important clinical risk factor to
adult patients undergoing surgery, the ACC/AHA guidelines
provided in 2014 failed to consider its importance in surgery
(Fleisher et al., 2014). This paper will discuss anesthesia for
patients with hypertension.
Pathophysiology of hypertension
Pathophysiology of hypertension is a complex issue because it
requires understanding of the vascular structure and functioning
of the endothelial malfunction. Similarly, essential hypertension
is created because of increased resistance from the vascular
tissue and a high level of vasoreactivity (de Waal et al., 2015).
The latter has severe consequences to blood pressure, and this
should be considered by an anesthetist.
Vasoreactivity has been found to be higher in hypertensive
patients than normotensive patients. This occurs because
limited vascular tone differences cause a change to blood

2. pressure of hypertension patients. As such, it causes an abrupt
fall or rise in the blood pressure. Secondly, baroreflex resetting
occurring in hypertension patients causes a shift in the flow of
blood to important organs (European Society of Cardiology,
2014). In this regard, a decrease in blood pressure causes an
equal reduction of blood flow to important organs of
hypertension patients. Lastly, the left ventricle (LV)
hypertrophy is specifically designed to tolerate high blood
pressure.
Hypertension is a worst condition during surgery of
hypertensive patients. Studies have shown that it is a form of
dreadful triad that can cause endocardium ischemia without the
patient having and problem of coronary complications. During
surgery, anesthesia induces sympathetic stimulation and high
blood pressure in hypertensive patients. For example, anxiety
before onset of surgery, stress and hypoxia have been found to
be common triggers of perioperative condition (de Waal et al.,
2015). However, vascular and cardiac surgery cannot be
controlled through cardiovascular regulation because tension to
the vascular sutures will result to inducing bleeding.
Currently, hypertension is not considered as an important risk
factor in predicting the amount of cardiovascular complications
(Fleisher et al., 2014). According to Le Manach et al. (2016),
hypertension is a dominant preoperative that does not occur in
multivariate models that are used to determine death. Other
epidemiology studies have shown that hypertensive patients
suffer from post treatment management. Therefore, all
hypertensive patients must be considered as being susceptible to
hemodynamic instability following surgery using anesthesia.
Where hypertension is not properly controlled, it acts as a major
indirect risk factor that can result to coronaropathy.
Consequences of Anesthesia to Hypertensive Patients. General
anesthesia has a major impact to sympathetic nervous system
and renin-angiotensin system (Lee et al., 2015). For example,

3. epidural anesthesia can lead to suppression of renin release as a
positive response to development of arterial hypotension (Lee et
al., 2015). Additionally, reduction of anesthesia to the
sympathetic tone in the vascular capacitance causes a decrease
of intravascular volume (Lee et al., 2015). This reduces the
blood pressure during administration of anesthesia because the
angiotensin II activity is suppressed by a competitive inhibitor
(de Waal et al., 2015). On the other hand, endogenous
vasopressin is directly involved in blood pressure control with
the aid of receptors concerned with vasoconstriction (de Waal et
al., 2015).
Secondly, blood pressure is created as a compromise from
cardiac impact and systemic vascular tone (de Waal et al.,
2015). As such, its regulation is influenced by the heart rate,
stroke volume of the LV and its resistance. Anesthesia blunts
the sympathetic nervous system (SNS), which has a major role
in blood pressure regulation. Where the SNS has blocked, RAS
is required to improve the situation after anesthesia has been
administered (European Society of Cardiology, 2014).
Therefore, anesthesia causes a decrease in blood pressure,
which results from the activity of RAS blockade and antagonism
from V1 receptors (European Society of Cardiology, 2014).
Anesthesia and Antihypertensive Drugs. The effects caused to
the SNS results to administration of different management
approaches. For example, propofol has a major impact to the
level of vascular reactivity, which reduces the response of the
vascular tissue to vasopressin. In hypertension patients, this
level of antagonism is amplified (de Waal et al., 2015). Also,
refractory hypotension has been linked to propofol effect in the
body. Consequently, chronic treatment should be given during
surgery.
Management of Hypertension Patients. It is important that the
stage of hypertension should be determined by an anesthetist
before surgery is undertaken. Patients treated with severe anti-
hypertensive drugs can be considered to be at higher risk of

4. developing hemodynamic uncertainty (Lee et al., 2015).
Secondly, it is important to identify the damage caused to end-
organs to form the basis of grading patients. Here, transthoracic
echocardiography can be used evaluate LV hypertrophy to
reduce risk of LV unpriming (European Society of Cardiology,
2014).
Titration can be used as a procedure for anesthesia induction
where severe hypertension grade is established. Propofol affects
vasoreactivity, which causes development of hypertension and
reduced by slow induction (de Waal et al., 2015). Thirdly, blood
pressure monitoring should be observed and complemented with
intermittent measurements. Therefore, continuous measurements
using arterial lines are an important consideration for
emergency cases of surgery for patients with high hypertension.
As a management strategy, it is important to avoid any build-up
of blood pressure in hypertension patients. This is important
because it will reduce any chances of bleeding during the
surgical process (de Waal et al., 2015). In the process of
surgery, using anesthesia like sevoflurane initiates development
of sympathetic blockade and this can reduce blood pressure.
However, it is important to add antihypertensive diagnosis (de
Waal et al., 2015). Similarly, it is important to control shivering
because it is important to the titration process using drugs like
nicardipine and esmolol.
Lastly, treatment of chronic hypertensive patients must be
addressed as soon as possible, especially where it forms part of
the multidrug regimen as a basis of preventing development of
cardiovascular risks (Lee et al., 2015). In order to manage the
perioperative period characterized by hemodynamic instability,
beta-blocker can be utilized (Fleisher et al., 2014). Therefore, it
is important for the doctor to resume treatment immediately

5. with angiotensin receptors as a basis or reducing postoperative
death of hypertension patients (European Society of Cardiology,
2014).
Conclusion. Hypertension remains an important concern for
anesthetist before performing any surgery procedures. This is
important because it forms the first etiology in the development
of severe cardiovascular diseases for aged patients undergoing
surgery. Secondly, HTA management has improved, but
majority have failed to control hypertension during surgery.
Therefore, a proper understanding of pathophysiology, little
consideration of risk caused by antagonism of anesthesia and
chronic treatment, security of drugs used and antihypertensive
IV diagnosis of an important platform for anesthetist to prepare
treatment and management of perioperative period.
References
de Waal, B., Buise, M. & van Zundert, A. (2015). Perioperative
statin therapy in patients at high
risk for cardiovascular morbidity undergoing surgery: a review.
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European Society of Cardiology (2014). ESC/ESA Guidelines
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Fleisher, L., Fleischmann, K., Auerbach, A., Barnason, S.,
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ACC/AHA Guideline on Perioperative Cardiovascular
Evaluation and Management of
Patients Undergoing Noncardiac Surgery. Circulation 130(1):
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Lee, S., Takemoto, S. & Wallace, A. (2015). Association
between Withholding Angiotensin
Receptor Blockers in the Early Postoperative Period and 30-day
Mortality.
Anesthesiology, 123(1): 288-230.
Le Manach, Y., Collins, G., Rodseth, R., Le Bihan-Benjamin, C.

6. & Biccard, B. et al. (2016)
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(POSPOM): Derivation and
Validation. Anesthesiology, 124(1): 570-579.