This document discusses peri-operative hypertension and provides recommendations for its management. It defines peri-operative as referring to the pre-operative, intra-operative, and post-operative periods of surgery. While stage 1 or 2 hypertension alone may not increase perioperative risk, the presence of target organ damage from hypertension can affect outcomes. The guidelines recommend continuing most antihypertensive medications during surgery, with the exception of ACE inhibitors and ARBs. For patients with grade 1 or 2 hypertension, there is no evidence delaying surgery to optimize therapy provides benefits. Acute postoperative hypertension is a frequent complication that should be treated to avoid adverse events.

1. Magdy El-Masry
Prof. of Cardiology
Tanta University

2. Peri-operative Hypertension
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.

3. Hypertension is most common medical reason for postponing surgery
Peri-operative hypertensives are very very common

4. 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 .

5. 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
perioperative risk.
Hypertensive comorbidities
associated with adverse
perioperative outcomes
include occult CAD(Q waves
on the ECG),heart failure, LVH,
serum creatinine higher than
2.0 mg/dL, and
cerebrovascular disease

6. Hypertension is not included

7. Laryngoscopy & intubation are known causes of hypertension( Sympathetic activation )

8. 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

9. To operate or not to operate,
that is the question.

10. 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
occasion?
Are they on antihypertensive medication?
Does the patient have a treatable cause for their
hypertension?
Does the blood pressure control need alteration before
surgery?
Does the patient have “white coat” hypertension?

11. 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).

13. 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
cardiovascular events.

14. 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
treated
Suspicion of secondary hypertension without properly documented aetiology

15. There are no randomized clinical trial data
showing what the optimal blood pressure
should be at the time of surgery.

16. What do guidelines tell us?

17. New Guidelines for managing patients with high blood pressure before surgery
The Association of
Anaesthetists of Great Britain
and Ireland (AAGBI)

18. Why was this guideline developed?
This guideline aims to prevent the diagnosis of hypertension
being the reason that planned surgery is cancelled or delayed.
Anaesthetists are
more focused on
immediate
complications, in
the perioperative
period.
Cardiologists
are concerned
with the long-
term reduction in
rates of CVD,
particularly
strokes.

19. Primary care blood pressure assessment of patients before referral for elective surgery.

20. 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

22. 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

24. 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,
antihypertensive
medications should be
continued during the
perioperative period.

25. Preoperative antihypertensive medications
management
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.

26. The American Society of Anaesthesiology classification of physical status(ASA)

27. Recommendations on use of ACEIs and ARBs

28. Recommendations
on beta-blockers
d Treatment should ideally be
initiated between 30 days and (at
least) 2 days before surgery, starting
at a low dose, and should be
continued post-operatively.
The target is a resting heart rate 60–
70 bpm, and systolic blood pressure
>100 mm Hg.

29. Perioperative use of beta-blockers may benefit only
patients at highest risk and may harm other patients.

30. 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
postoperative period
and lasts an average of
3 hours

31. Parenteral antihypertensive agents for treatment of perioperative hypertension
Abbreviation: CI, continuous infusion.
To solve an APH, several pharmacological solutions turned out to be efficient.

33. Preoperative Intraoperative Postoperative
SAP ≤ 180 mmHg,
DAP≤110 mmHg
MAP not lower
than 25–30% of
awake
Resume antihypertensive drugs upon oral
intake or substitute i.v.
ECG, serum creatinine,
electrolytes (diuretics)
search for target organ
damage (heart, brain,
kidney)
Attenuate
sympathetic
response to
laryngoscopy (or
use laryngeal mask)
Measure blood pressure every 5–15 min
first hour then every 30 min until 3 h
postoperative
Antihypertensive drugs;
continue day of surgery:
b-blockers, CCB;
stop day of surgery:
diuretics, ACEI, ARB
Consider use of
noninvasive cardiac
output monitoring
and near-infrared
spectroscopy (NIRS)
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