Hypertension and Anesthesia

Anesthesiologist Dilemma;
Preoperative Hypertension:
to Treat and Operate, or to Postpone
Surgery ??
Dr. Anuj Jung Karki
Asst. Prof, Anesthesiologist
NAMS, Bir Hospital

Anesthesiologist’s Dilemma…
• 72years/Female
• Case of closed IT # left
femur
• Plan: DHS
• BP 178/100 mmHg
• No any signs target organ
damage
• Investigations :WNL
• Tab. Amlodipine 5mg OD

Epidemiology
Global
• 40% of the world adult are
hypertensive.
Nepal
• 18.8% to 41.8%.
• Tripling of prevalence from 1981 to 2006
1. WHO 2008
2. Subama M Dhital et al Dealing with the burden of hypertension in Nepal:
current status, challenges and health system issues Regional Health Forum –
17(1)2013

•N= 955
• Incidence of hypertension in PAC 10.16%.
•Maximum 50-59 years (26.6%)
• 52% were patients with newly diagnosed
hypertension
2011

SBP DBP
Optimal <120 mmHg < 80 mmHg
Normal 120-129 mmHg 80-84 mmHg
High normal 130-139 mmHg 85-89 mmHg
Hypertension
Stage 1 140-159 mmHg 90-99 mmHg
Stage 2 160-179 mmHg 100-109 mmHg
Stage 3 180-209 mmHg 110-119 mmHg
Stage4 >210 mmHg > 120 mmHg
Isolated Hypetension >150 mmHg <90 mmHg
Classification of Hypertension
James MFM, Rayner BL. A modern look at hypertension and anaesthesia. South Afr J Anaesth Analg. 2011; 17 (2): 168-173.

Hypertension is one of the common reason
of postpone of surgical list by
anesthesiologist

Ismat et al Sudan Medical Monitor|2016

Mesmar et al Eastern Mediterranean Health Journal/ 2011

Past:
•Pre-operative hypertension is associated with an
increased risk of perioperative major cardiovascular
events and/or mortality .
Current:
•Omission from various risk stratification algorithms
• Fall in profile of this condition

 Hospital acquired infection
 Cost
 Psychological consequences
Postponement

Hemodynamic instability*
Heart Failure
Fatal Arrhythmias
Myocardial infarction
Cerebral adverse events
Mortality
Risks to proceeding??

• Is It Really Justifiable to Postpone
Hypertensive Surgical Patients?

Sprague HB. The heart in surgery. An analysis of the results of surgery on cardiac patients during the past ten years at the
Massachusetts General Hospital. Surg Gynecol Obstet 1929; 49: 54–8
• Sprague first identified an association
between hypertension and perioperative
cardiac risk in 1929.
• He described a series of 75 hypertensive
patients of whom one‐third died in the
perioperative period; 12 of these had
cardiovascular complications.
Historical background

• Published several publications
titled ‘Studies of Anaesthesia
in relation to hypertension, I-
VII’ covering a period of 15
years, 1971 – 1986.
Cedric Prys-Roberts
Historical background…

• 25% of the hypertensive- significant decreases BP that
led to ischaemic changes.
• Well controlled hypertensive behaved in a similar
manner to the normotensive patients.
Conclusion
• Untreated high arterial pressure constitutes a serious
risk to patients undergoing surgery
• Antihypertensive therapy should not be withdrawn
prior to anaesthesia without a compelling reason.
C. Prys Roberts etal Brit. J. Anaesth.1971

This recommendation led to a major change in
anesthetic practice during that period.
The recommendations of Prys-Roberts and
colleagues therefore need to be reconsidered in the
light of the modern views of hypertension and its
management.
Historical background

• Prospectively studied (1975-1976)
• N= 676 Patients under going elective general
anesthesia .
• Divided into 5 groups
Effective intraoperative management may be more
important than preoperative hypertension control
for significant BP liability and cardiovascular
complication in patient with mild to moderate
hypertension

•A systematic review and meta‐analysis of 30 observational
studies
•Demonstrated an odds ratio for the association between
hypertensive disease and perioperative cardiac outcomes of
1.35 (1.17–1.56).
•This association is statistically but not clinically significant.
•Little evidence for an association between admission SBP
<180mmHg or 110 mmHg DBP & perioperative
complications.
• Surgery should not be cancelled on the grounds of
elevated preoperative arterial pressure.
• The intraoperative arterial pressure should be
maintained within 20% of baseline.
• Attention should be paid to the presence of target
organ damage & other risk scores.

Curr Opin Anesthesiol 2016
Target organ damage associated with hypertensive disease
and total cardiovascular risk, rather than high BP per se
appear to determine perioperative risk.
Isolated systolic hypertension with increased pulse pressure
and diastolic dysfunction predominates in the elderly and
constitutes a particular perioperative risk profile.
Monitoring techniques based on near-infrared spectroscopy
show promise for real time assessment of autoregulation
limits
Key Points

• Prospective randomized 989 patients for stage 3
Hypertension (DBP 110~130 mmHg) without clinical
risk factors : Compared delayed operation with
immediate BP control with Nifedipine
• Control group: Surgical procedures postponed and
remained in the hospital for control of BP.
• Study group : Immediate BP control with Nifedipine
No significant differences in Peri-operative
complications

5 different case scenarios with multiple case information
and questioners were sent regarding patient with stage
2,3 & 4 hypertension to the anesthesiologist sent via
mail of south western service of UK (n = 488)
Key points:
• Stage 1 and 2 Hypertension: Surgery proceed
• Stage 3 and 4 Hypertension: Deferred and treatment of
high BP

Isolated Systolic Hypertension and
Peri-operative adverse events

•2417 patients undergoing CABG in 24 medical centers
• Normotensive, ISH(>140 mm Hg), DBP (>90 mmHg),
or a combination of these
• ISH associated with a 40% increased risk of adverse
outcomes (odds ratio, 1.4; confidence interval, 1.1–
1.7).
•Increased risk of adverse outcomes with ISH was 30%.
Solomon et al 2002
ISH is associated with a 40% increase in the
likelihood of cardiovascular morbidity peri-
operatively in CABG patients

Peng et al. Excessive lowering of blood pressure is not beneficial for progression of brain white matter hyperintensive and
cognitive impairment in elderly hypertensive patients: 4-year follow-up study. J Am Med Dir Assoc 2014
• Attempts to decrease SBP toward ‘normal’
ranges may cause diastolic hypotension and
organ Hypo-perfusion.
ISH and…
• There is no such study till to examine the
impact of isolated systolic hypertension on
outcome in non‐cardiac surgery .
• Reasonable to postpone if ISH> 180 mmHg

PP Hypertension &
Perioperative adverse events

Pulse Pressure and Risk of Adverse Outcome in
Coronary Bypass Surgery
•4801 patient undergoing for CABG in CPB
•SBP,DBP & PP hypertension and perioperative complication
using multivariable logistic regression.
•19.1% patients had fatal and non fatal vascular complications
• Hospital mortality 3.1% & PP hypertension was strongly
associated with it.
•Incidence of cerebral events/or mortality nearly doubled in PP>
80 vs < 80 mmHg(5.5% vs 2.8%)
•PP > 80mmHg increased incidence of 52% .
Manuel L. Fontes et al in 2008
• PP hypertension independently and
significantly associated with greater fatal and
nonfatal adverse events in CABG.

•The relationship between PP and hemodynamic
instability index was assessed using multiple
regression analysis.
•63% of hypertensive subjects had a PP > 60 mmHg.
•Among hypertensives
49% had no DD
31% had a mild DD
20% had a moderate or severe DD
J Anesthe Clinic Res 2011
• Hemodynamic instability was significantly higher
in hypertensives.
• Hypertensive patients with and without DD had
similar hemodynamic instability index.
• This index was positively correlated with PP(p <
0.0001)

In cardiac surgery, high preoperative pulse pressures
have been associated with fatal & non fatal cardiac
events
This has not been consistently observed in patients
under going non-cardiac surgery
PP hypertension…

LVH & DD in hypertensive patients

•Diastolic dysfunction with LVH, is a specific syndrome that
affects cardiovascular reserve and may evolve to a distinct type
of heart failure with preserved ejection fraction.
•Poor tolerance to hypovolemia.
• Increased risk for fluid overload.
• Patients have very narrow margins for fluid optimization.
1. Tannenbaum S et al Advances in the pathophysiology and treatment of heart failure with preserved ejection fraction. Curr
Opin Cardiol 2015
2. Nicoara A et al Diastolic dysfunction, diagnostic and perioperative management in cardiac surgery. Curr Opin Anaesthesiol
2015
LVH & DD…

•Reversal of LVH with therapy and improvement on ventricular
function with adequate control of BP in 12 to 24 months.
•Reversal of LVH and blood pressure control in improves
diastolic function
New monitoring techniques such as echocardiography and
dynamic preload assessment is helpful in guiding volume
therapy during major surgery
LVH & DD….
1. Schlant et al. Echocardiographic studies of left ventricular anatomy and function in essential hypertension. Cardiovasc Med
1977
2. Trimarco B et al. Improvement of diastolic function after reversal of left ventricular hypertrophy induced by long-term
antihypertensive treatment with tertatolol.Am J Cardiol 1989

Hypertension in Intraoperative
Risk Stratification

RISK FACTORS POINTS
Age > 70 y/o 5
MI in previous 6 months 10
S3 gallop or JVE (+) 11
Important Aortic Stenosis 3
Rhythm other than Sinus or PACs on last preoperative ECG 7
> 5 VPCs/min documented at any time before OP 7
PaO2 < 60 or PaCO2 > 50 mmHg; K < 3.0 or HCO3 < 20 mEq/L;
BUN > 50 or Cr > 3.0 mg/dL; Abnormal AST, Signs of chronic
liver disease, or Bed-ridden from Noncardiac Causes
3
Intraperitoneal, intrathoracic, or aortic operation 3
Emergency operation 4
Goldman Multifactorial Cardiac Risk Index
Hypertension??

Revised Cardiac Risk Index
Hypertension??

Components
• Type of surgery
• Functional status of patient
• Serum creatinine
• ASA PS
• Age
Hypertension??

Postponing stage 1 & 2
Hypertension
Risk Stratification…

Pre-operative evaluation of hypertensive
patient; Questions to be answered
• What should be the Cutoff BP value to postpone
elective surgeries?
• If postponed, What should be the Target of BP?
• If postponed, what should be Time Duration of BP
optimization?
• When does Autoregulation Curve shift towards
normal area?
• What is the Target intraoperative blood pressure?

•Common Practice to postpone surgery
DBP>110 mmHg, SBP>180 mmHg
•Increased risk of perioperative dysrhythmia,
Myocardial ischemia, MI stroke
Cutoff value…
1. Prys-Roberts in 1971
2.Goldman and Caldera in 1979
3.ACA/AHA 2014

• The overall incidence of adverse events
 elevated troponin levels 1.3%
 in-hospital death 2.8% with subgroup with
baseline SBP> 200 mmHg.
Cutoff value…
Varon J, Marik P. Perioperative hypertension management. Vascular Health Risk Management. 2008;3:615–
627.

Patients < years of 60: <140/90 mmHg
Patient with diabetes:140/90 mmHg
Patient with CKD:<140/90 mmHg
Patients> 60 years : < 150/90 mmHg
Target BP
JNC 8

• For elective surgery, effective blood pressure
control can be achieved over several days to
weeks of outpatient treatment.
Duration of BP reduction

BP reduction strategies
Should be achieved gradually unless there is concomitant
hypertensive emergency
There are no controlled studies demonstrating long-term
improved outcomes with acute treatment of severe
asymptomatic hypertension
Reducing severely elevated blood pressure below the
autoregulatory zone too quickly can result in markedly
decreased perfusion to the brain and eventually ischemia or
infarction.
No role of cosmetic correction of asymptomatic
uncontrolled hypertension

How rapidly blood pressure is to be
reduced in asymptomatic 3 & 4
hypertension??

Shift of autoregulation curve
towards normal

Drug treatment reversed the adaptive changes in the heart and
peripheral resistance vessels in 3-5 weeks in SHR
Am J Pathol 1983, 111:380-393

It is very reasonable to wait at least 4 weeks
for vascular(arterial and myocardial)
adaptation with normalization of
autoregulation.

Newly diagnosed stage 1 and 2 hypertension
without or minimal target organ hit

• Perioperative
hemodynamic fluctuations
occur less frequently in
treated than in untreated
hypertensive patients

Proceed for surgery with starting the
antihypertensive medication before
surgery

Bijker JB et al: Incidence of intraoperative hypotension as a function of the chosen definition: literature definitions
applied to a retrospective cohort using automated data collection. Anesthesiology 2007
Targeting intra-operative BP
• Evidence-based, intra-operative haemodynamic
targets are urgently required.
• Systolic or mean arterial pressure ± 20% (sweet
spot) of a pre-operative measurement is often
recommended.

Cardiac adverse event were more likely to experience an
episode of MAP < 50 mmHg or 40% decrease in MAP, and
an episode of HR > 100 bpm
Together, these data suggest that maintenance of
normal blood pressure is critical in patients with
hypertension

• Try to maintain intraoperative BP ± 20% of
baseline (around ± 20% )
• Prevent & treat Hypotension promptly

•Preoperative B-type natriuretic peptide could be a useful
adjunct for risk stratification (but insufficient evidence for
routine screening test)
•Recent studies show that processed near-infrared
spectroscopy (NIRS) information in relation to changes in
BP allows for noninvasive assessment of autoregulation.
•An increase in pulse wave velocity by 1 m/s was reported to
cause a 15% adjusted risk increase.
•It may prove valuable risk indicator in the preoperative
assessment of hypertensive patients.
Recent Advances

Conclusion

Watch out for intraoperative labile & fluctuation blood
pressure.
Stage 1 & 2 Hypertension
Patients with stage one and two hypertension who do not
have evidence of organ dysfunction; proceed to surgery
Although surgery may not have to be delayed but
appropriate referrals should be made so that patients will
have future appropriate postoperative management of
inadequately managed hypertension
Significant target organ involvement should be considered
for preoperative treatment

Go
for it
Wait
Stage 1 & 2 Hypertension

Stage three hypertension, it is probably justified
to postpone elective surgery to investigate for
target organ damage and to institute therapy.
Stage 3 Hypertension

•These patients need to be on treatment for 4 to 6
weeks before surgery.
Stage 4 Hypertension
•Stage 4 hypertension appear to present a significant
perioperative risk. Surgery should be deferred for
treatment.
•There is no place for “cosmetic correction”
immediately prior to surgery

ISH > 180 & PP > 80 mmHg reasonable to postpone
for optimization of BP
Significant Target Organ Damage & other risk
factors taken in consideration
ISH & PP Hypertension

But Rememberǃǃ
Hypertension has disappeared from clinical risk
from perioperative guidelines, this does not
mean that hypertension is no longer a
concern for the perioperative period.
LV hypertrophy, tachycardia and hypotension
are a dreadful triad in hypertensive patient

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