Anaesthetics Supplement: Hypertension and Anaesthesia

Hypertension and Anaesthesia

Lines D, Department of Anaesthesia, Chris Hani Baragwanath Academic Hospital, University of Witwatersrand
Correspondence to: Des Lines, e-mail: [email protected]

Abstract
The difficulty that anaesthetists face is that they often, when seeing a patient pre-operatively, do not have the benefit
of seeing the patients normal average blood pressure taken at different times over a period of weeks. The decision
to cancel surgery based on the blood pressure found at the pre-operative visit must, therefore, take into account the
urgency of the surgery, as well as the presence of end organ damage from chronic hypertension. A detailed history and
examination should be performed looking for evidence of coronary artery disease, cerebrovascular disease and renal
dysfunction.
Peer reviewed Medpharm S Afr Fam Pract 2014;56(2)(Suppl 1):S5-S9

Introduction and is classified as optimal, normal, high normal and then

hypertension stage 1-3.5 Some authors include additional
Hypertension affects more than 1 billion people
categories viz. stage 4, isolated hypertension and pulse
worldwide, and is a major risk factor for coronary
pressure hypertension as seen in Table I.4 When the arterial
artery disease, myocardial infarction, cardiac failure,
pressure falls in different categories of systolic and diastolic
stroke, cerebrovascular events including dementia,
pressure the higher category applies.
atherosclerosis and the development of renal failure. It is
also associated with dyslipidaemia, diabetes and obesity.1 Isolated systolic hypertension accounts for the majority
The incidence of hypertension, and in particular systolic of hypertension in patients over 50 years of age and is
hypertension, increases with age. It is estimated that defined as a systolic blood pressure above 140 mmHg
60% of the worlds adult population are hypertensive as (or 150 mmHg as per JCN8 classification) and a diastolic
defined by The World Hypertension Society/International pressure of less than 90 mmHg.5 Systolic blood pressure
Society of Hypertension (WHO/ISH).2 increases with age whereas diastolic pressures tend to
reach a plateaux in the fifth or sixth decade of life.3 Older
Aetiology and classification patients have less compliant vessels and hence the higher
The majority of the worlds hypertensive population systolic pressures and higher pulse pressures recorded.
(95%) suffer from essential hypertension, implying that Pulse pressure hypertension (>80 mmHg) has now been
the cause of the disease is unknown. The remaining recognised as a significant risk for both myocardial
5% of hypertensive patients suffer from secondary infarction and stroke.
hypertension where the cause of the hypertension is as
a result of a medical condition.3 Secondary
hypertension should always be considered
Table I: Classification of blood pressure
in the younger patient group as well as in
patients where the hypertension is not easily Systolic blood pressure Diastolic blood pressure
controlled by conventional treatment. Optimal Less than 120 mmHg Less than 80 mmHg
Normal 120-129 mmHg 80-84 mmHg
It is an undisputed fact that chronic
hypertension should be treated to decrease High normal 130-139 mmHg 85-89 mmHg
the risks associated with an elevated blood Hypertension
pressure. As will be discussed below, there is a Stage 1 140-159 mmHg 90-99 mmHg
considerable difference of opinion as to what Stage 2 160-179 mmHg 100-109 mmHg
the threshold blood pressure is for starting a Stage 3 180-209 mmHg 110-119 mmHg
Stage 4 Greater than 210 mmHg Greater than 120 mmHg
patient on treatment and what the target
levels are that need to be met. The severity Isolated hypertension Greater than 150 mmHg Less than 90 mmHg
of hypertension is classified according to a Pulse pressure hypertension Greater than 80 mmHg
band of increasingly severe hypertension Source: James MFM et al3

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Targets for treatment A survey published in the British Journal of Anaesthesia, in

2001, by Dix and Howell, showed a great variability amongst
There is differing opinion as to the threshold value where
anaesthetists as to which patients would be cancelled.6
treatment needs to commence. The latest Joint National
This makes consensus protocols difficult to agree on, in the
Committee on prevention, detection, evaluation and
light of such variation in practice. Guidelines also often
treatment of high blood pressure (JNC8) published
assume the same easy access to testing and specialist
guidelines in December 2013 in the Journal of the
care and may sometimes be difficult to apply in resource
American Medical Association (JAMA) which have
limited settings. The difficulties faced by the anaesthetist
relaxed treatment goals in the older population groups.
in the peri-operative period relate to a number of issues:
These treatment goals are now summarised as follows in
The patient may be identified for the very first time as
the JNC8 document:
suffering from high blood pressure and this may never
In patients 60 years or older, start treatment in blood
have been investigated or treated.
pressures >150 mmHg systolic or >90 mmHg diastolic
The anaesthetist may see a patient immediately before
and treat to under those thresholds.
surgery and may make a diagnosis of hypertension
In patients <60 years, treatment initiation and goals based on a single reading pre-operatively.
should be 140/90 mmHg, the same threshold used in
The patient may already be on treatment but the
patients >18 years with either chronic kidney disease
blood pressure immediately before surgery is beyond
(CKD) or diabetes.
acceptable limits to the anaesthetist.
In non-black patients with hypertension, initial treatment
The patient may have been postponed a few days
can be a thiazide-type diuretic, calcium channel
before for blood pressure control and now presents
blocker (CCB), or angiotensin converting enzyme
having been on medication for only a few days.
inhibitor (ACE), or angiotensin receptor blocker (ARB),
The hypertensive patient who is over-medicated may
while in the general black population, initial therapy
have a low blood pressure and or pulse rate.
should be a thiazide-type diuretic or CCB.
The patients blood pressure is markedly raised before
In patients >18 years with CKD, initial or add-on therapy
surgery but the surgery is of an emergent nature.
should be an ACE inhibitor or ARB, regardless of race or
diabetes status.5 A lack of randomised controlled trials indicating
whether hypertensive patients per se are at an
The American Heart Association (AHA) and American increased risk of peri-operative adverse events.
College of Cardiology (ACC) do not support these The hypertensive patient who has a raised blood
guidelines. One of the major areas of disagreement is pressure as a result of a medical condition e.g. the
the raising of the target blood pressure in the 60 plus age patient in renal failure where the blood pressure
group from 140 to 150 mmHg. Without this consensus, cannot adequately be controlled.
the management of the elderly hypertensive patient
may not be clear. A further area of controversy relates Target organ damage
to the trigger level where blood pressure treatment
The impact of hypertension on the risk of developing an
needs to commence. There is a body of opinion that
adverse peri-operative myocardial event has been the
suggests that healthy patients with stage 1 hypertension
focus of numerous studies. Prys-Roberts and colleagues
are unnecessarily started on treatment and exposed to
showed an increase in arrhythmias and post-operative
the side effects of these drugs without any evidence of
myocardial infarction in a small population of hypertensive
benefit. While diastolic blood pressure used to be the main
patients during the early 1970s.7 Goldman and Caldera,
target of antihypertensive therapy, it has now become
in 1979, looked at a larger study population and failed to
evident that systolic blood pressure and an increase in
show any difference in adverse outcome between treated
pulse pressure above 65 mmHg is more important in terms
and untreated hypertension.8 More recently, Howell and
of outcome, especially in the patient population above
colleagues, from Oxford, did an extensive literature review
50 years of age. The benefits of treating isolated systolic
and meta-analysis of 30 observational studies. They found
hypertension are now clearly established and carry a
that the odds ratio for an association between elevated
greater risk to the patient of developing a cardiac or
admission blood pressure and an adverse cardiac event
neurological incident.
was 1.35 (95% CI 1.17-1.56). There was little evidence that,
Hypertension together with low serum potassium probably if pressures were less than 180 mmHg systolic and less than
account for more unnecessary cancelations of surgery 90 mmHg diastolic, that there was an increased likelihood
than any other condition. Until a more rational approach of an adverse peri-operative event. The position is less
to hypokalaemia in the mid-1980s, anaesthetists routinely clear for patients with pressures above these levels.9 This
would postpone surgery demanding that these patients study does cast doubt that the peri-operative outcome
have their serum potassium normalised before surgery. A was any different in hypertensive patients compared with
rational approach to the hypertensive patient presenting normotensive patients despite the fact that hypertensive
for surgery is needed so that unnecessary cancelations patients with pressures greater than 180/110 mmHg tended
can be avoided based purely on a blood pressure reading. to have greater haemodynamic instability, myocardial

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ischaemia and arrhythmias. The heterogeneity of the limit myocardial perfusion. Subendocardial autoregulation
studies analysed with regards the type of complications is also abnormal making hypertensive hearts vulnerable
and likely risk, did however make effective correction for to unstable blood pressures.3 An exaggerated pressor
confounding variables very difficult. Current evidence response may also occur during severe surgical stimulation
would suggest, and is supported by the ACA/AHA and extubation.
guidelines that stage 1 or stage 2 hypertension alone is
These responses and the haemodynamic instability that
not an independent risk factor for peri-operative cardiac
occurs in hypertensive patients resulting in intra-operative
complications. The recommendations regarding patients
ischaemia can be modified by treatment and requires the
with pressures exceeding 180/110 mmHg are less clear and
understanding and appropriate skill of the anaesthetist
a risk-benefit analysis needs to be made before pending
to modify these effects. Patients with stage 3 or greater
surgery. A recent study did, however, show that increasing
hypertension will have greater fluctuations in blood pressure
severity of pre-induction hypertension was an independent
during anaesthesia and as this level of hypertension may
risk factor for myocardial injury/infarction and in-hospital
be a marker for potential coronary heart disease (CAD), it
death. The overall incidence of adverse events (elevated follows that control of blood pressure pre-operatively may
troponin levels or in-hospital death) was 1.3% and 2.8% help reduce the tendency to peri-operative ischaemia
for the subgroup with baseline systolic pressures above and hence post-operative cardiac morbidity.10
200 mmHg.20 Crucial to all of this is determining whether
the hypertension occurs in isolation, is associated with Brain
complications related to the existence of long standing
Hypertension is a risk factor for ischaemic and haemor-
hypertension or if it is associated with other risk factors.
rhagic brain injury. Carotid disease is also more common
The major organs at risk from long standing, untreated
in patients with hypertension, making them vulnerable
hypertension are the heart, the kidneys and the brain. The
to a cerebral ischaemic event if pressures are not
physical examination should include a search for target
appropriately controlled in the peri-operative period.
organ damage and evidence of associated cardiac, Chronic hypertension leads to a shift in the cerebral
renal and cerebral pathology. The review by Howell and autoregulation curve to the right, making cerebral
colleagues implies that patients are more likely to die perfusion flow dependant, during severe hypotension.
from hypertension related co-morbidities or from a poor Normalisation of the cerebral autoregulation may take
understanding of the pathophysiology of hypertension several weeks to return to near normal values.
and its relation to anaesthesia than from the hypertension
per se.1 Kidney

Heart Loss of autoregulation in the kidneys in hypertensive

patients will also increase the risk of renal failure with
Hypertension leads to increased myocardial wall tension hypotensive episodes.
and an increase in oxygen demand. This together with
concentric hypertrophy and the development of diastolic Pulse pressure hypertension has been shown to increase
dysfunction leads to an imbalance in myocardial oxygen the risk of post-operative renal failure, strokes and to
supply and demand. As the muscle hypertrophies and significantly increase the risk of myocardial infarction.13
becomes stiffer the left ventricular end diastolic pressure High pulse pressure hypertension (greater than 60 mmHg)
(LVEDP) increases, which leads to a decrease in coronary may also contribute significantly to intra-operative
perfusion pressure. The recognised association of chronic haemodynamic instability and may be a more important
hypertension and coronary artery disease sets the scene for predictor than diastolic dysfunction.15
intra-operative ischaemia and arrhythmias, particularly, if
associated with haemodynamic instability. The vulnerable Management
times peri-operatively are at the time of induction and The anaesthetist generally only has a short time before
intubation, immediately post induction, during surgical surgery to evaluate a patients fitness for surgery and
stimulation and again at the end of the procedure during uncover potential risks. Medical funders do not allow
extubation. Intubation may lead to an exaggerated admission to hospital the day before surgery as was the
pressor response and agents such as short acting opioids, custom years ago, so patients are only admitted on
esmelol, glyceryl trinitrate or magnesium sulphate can be the morning of surgery. The diagnosis of hypertension
used to control this response. It is worth remembering that on a single blood pressure reading may lead to an
an exaggerated blood pressure response intra-operatively incorrect diagnosis and may even result in a patient
may be due to an undiagnosed phaeochromocytoma being prescribed chronic anti-hypertensive medication,
with excess catecholamine secretion and in this instance unnecessarily. In patients who are already admitted to
a beta blocker will be contra-indicated. Magnesium hospital the anaesthetist is in a better position to assess the
sulphate, as a bolus of four grams, is probably the hypertension as they will have the benefit of ward blood
safest and most effective first line treatment.3 Following pressures taken at different times over days or weeks.
induction, the pressures may decrease due to a lack of This does not imply that a single high reading should
stimulation resulting in a low diastolic pressure which may not prompt further investigation, as the pre-operative

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evaluation is a unique opportunity to identify patients Emergency surgery

with hypertension and initiate appropriate treatment. The
Emergency surgery should not be delayed because of
Oxford group, led by SJ Howell, were not able to show a
a high blood pressure. A gentle lowering of the blood
clear association between admission arterial pressure and
pressure with short acting agents before induction may
major peri-operative cardiac complications.11, 12
be appropriate. An appropriate anaesthetic technique to
White coat hypertension control haemodynamic instability is required.

White coat hypertension is very relevant to anaesthetic Post-operative hypertension

practice. Anaesthetists do not as a routine have the luxury
Hypertensive patients may develop severe hypertension
to take a blood pressure on a number of occasions over
in the immediate post-operative period. A thorough
a period of weeks before the diagnosis of hypertension is
investigation into the cause is mandatory before treatment
made. White coat hypertension is defined as an office/
is started. Common causes of hypertension that need to
pre-surgical blood pressure of greater than 140/90 mmHg
be excluded are pain, full bladder, ventilatory challenges,
with an average daytime reading of less than 135/85
hypothermia, a cerebral event and serious endocrine
mmHg.1 Studies have not shown an increase in long
causes such as thyroid storm, phaeochromocytoma and
term cardiovascular events to be any different from
as a result of withdrawal of their long term anti-hypertensive
normotensives.14
drugs. The levels at which intervention are required are ill
Pseudo-hypertension (Oslers sign) defined and will depend on the patients pre-operative
status. As with pre-operative hypertension, a persistent
Pseudo-hypertension occurs when the blood vessels are
blood pressure in excess of 180/110 mmHg after the causes
so calcified and non-compliant that they do not collapse
discussed above have been excluded may warrant
when the blood pressure cuff is inflated so giving a falsely
intervention, particularly in patients with known coronary
elevated systolic blood pressure.16
artery disease or those at risk of cerebrovascular accidents
Anti-hypertensive agents or bleeding. Blood pressure should be decreased slowly
over 30-60 minutes and by no more than 25% or to a target
Most hypertensive patients will be on one of four groups or a
value less than 180/110 mmHg.20
combination of drugs for their hypertension. These include
thiazide diuretics, beta blockers, angiotensin converting Recommendations and conclusion
enzyme inhibitors (ACEI) or angiotensin II receptor blockers
(ARBs) or calcium channel blockers (CCBs). A review of The management of hypertensive patients in the peri-
their medication is important to identify potential problems operative period is controversial and because of a paucity
specific to each group. Anti-hypertensive therapy should of studies providing good evidence for sound clinical
in general be continued up until the day of surgery. management, general recommendations are difficult to
make. As was demonstrated in the survey done by Dix
Thiazides and Howell, there is great variability between anaesthetists
Chronic therapy may result in hypokalaemia. as to which hypertensive patients need to be cancelled.4
These decisions may depend on the level of training of
Beta blockers
the anaesthetists as well as institutional facilities, speciality
Abrupt withdrawal of beta blockers may result in rebound back up and protocols. The purpose of articles such as
hypertension and may precipitate angina. Beta blockers this is to ensure that no harm is done, that patients are
are no longer recommended to be started acutely in high not cancelled unnecessarily, and worse still, get put on
risk patients before surgery in the light of the published chronic treatment when it is not indicated. In 2004 Howell,
Perioperative Ischaemic Evaluation Study (POISE).18 The Sear and Fox stated that: There is little evidence for
POISE study showed that in spite of the fact that there was an association between admission arterial pressures of
a reduction in myocardial infarction, all-cause mortality less than 180 mmHg systolic or 110 mmHg diastolic and
and in particular stroke was increased. peri-operative complications. The position is less clear in
patients with admission arterial pressures above this level.
ACEI/ARBs
Such patients are more prone to peri-operative ischaemia,
These agents may blunt the compensatory activation of arrhythmias, and cardiovascular lability, but there is no
the renin angiotensin system during surgery and result in clear evidence that deferring anaesthesia and surgery in
prolonged hypotension. The data is insufficient to make such patients reduces peri-operative risk and concluded:
an absolute recommendation but it seems reasonable to We recommend that anaesthesia and surgery should not
continue them in patients taking them for the management be cancelled on the grounds of elevated pre-operative
of hypertension. It may also be reasonable to withhold arterial pressure. The intra-operative arterial pressure
them on the morning of surgery in patients taking them should be maintained within 20% of the best estimate of
for congestive heart failure in whom the baseline blood pre-operative arterial pressure, especially in patients with
pressure is low.17 markedly elevated preoperative pressures.2

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Based on the available evidence the following References

recommendations can be made: 1. Spahn DR. Editorial 11. Preoperative hypertension: remain wary? yes-
cancel surgery? No Br J Anaesth 2004;92(4):461-464.
Patients with stage one and two hypertension who do
not have evidence of organ dysfunction and without 2. Howell SJ, Sear JW, Fox P. Hypertension, hypertensive heart disease
and perioperative cardiac risk. Br J Anaesth 2004;92(4):570-583.
other risks (diabetes, renal dysfunction, and smoking)
3. James MFM, Rayner BL. A modern look at hypertension and
may proceed to surgery. anaesthesia. South Afr J Anaesth Analg. 2011; 17 (2): 168-173.
In patients with poorly controlled, stage three 4. Dix P, Howell SJ. Survey of cancellation rate of hypertensive patients
hypertension, it is probably justified to postpone elective undergoing anaesthesia and elective surgery. Br J Anaesth 2001;
surgery to investigate for target organ damage and to 86 (6): 789-793.

institute therapy. 5. James PA, Oparil S, Carter BL, et. al. 2014 Evidence-Based Guideline
for the Management of High Blood Pressure in Adults: Report From the
Patients with stage four hypertension appear to present Panel Members Appointed to the Eighth Joint National Committee
a significant peri-operative risk.3,20 Surgery should always (JNC 8). JAMA 2014 Feb 5;311(5):507-520.
be deferred for treatment. The controversy exists as 6. Dix P, Howell SJ. Survey of cancellation rate of hypertensive patients
to how long these patients need to be on treatment undergoing anaesthesia and elective surgery. Br J Anaesth 2001; 86
(6):789-793.
before rescheduling surgery. There is no place, as
stated by James et al for cosmetic correction 7. Prys-Roberts C, Meloche R, Fox P. Studies of anaesthesia in relation
to hypertension cardiovascular responses of treated and untreated
immediately prior to surgery. These patients need to patients. Br J Anaesth 1971; 43: 122-137.
be on treatment for four to six weeks before surgery, 8. Goldman L, Caldera DL. Risks of general anaesthesia and elective
with some re-adjustment of autoregulation in the major operation in the hypertensive patient. Anaesthesiology. 1979; 50:
organs.3 285-292.

In isolated systolic hypertension, where the pressure is 9. Howell SJ, Sear JW, Fox P. Hypertension, hypertensive heart disease
and peri-operative cardiac risk. Br J Anaesth 2004; 92: 570-83.
greater than 180 mmHg or the pulse pressure is greater
10. Slogoff S, Keats AS. Does perioperative myocardial ischemia lead to
than 80 mmHg, considerable debate exists. These
postoperative myocardial infarction? Anesthesiology 1985; 62: 10714.
patients do need treatment in the long term but it is
11. Howell SJ, Sear YM, Yeates D , Goldacre M , Sear JW , Fox Pc. Risk
controversial as to whether elective surgery should be factors for cardiovascular death after elective surgery under general
postponed, especially, in the patient without evidence anaesthesia. Br J Anaesth 1198; 80: 14-19.
of end organ damage. In these patients it is important 12. Howell SJ, Sear Y M, Yeates D, Goldacre M, Sear JW, Fox P. Hypertension
to consider the risk benefit ratio of delaying the surgery. admission blood pressure and peri-operative cardiovascular risk.
Anaesthesia 1996; 51:1000-1004.
For the anaesthetists who do not have the benefit of 13. Franklin SS, Khan SA, Wong N D, Larson MG, Levy D. Is pulse pressure
seeing the patients normal average blood pressure useful in predicting risk for coronary heart disease? The Framingham
which has been taken at different times over a period heart study. Circulation 1999;100:354-360.

of weeks and compounded by the well described white 14. Celis H, Staessen JA, Thijs L, Buntinx F, De Buyzere M, Den Hond E,
Fagard RH, OBrien ET. Cardiovascular risk in white-coat and sustained
coat hypertension, the decision to cancel surgery is
hypertensive patients. Blood Pressure 2002;11:352356.
complex and should take into account the urgency of
15. Balick Weber CC, Brillouet Banchereau AC, Blanchet AD, Blanchet P,
the surgery, as well as the presence of any end organ Safar ME, et al. General Anesthesia in Hypertensive Patients: Impact of
damage resulting from chronic hypertension. A detailed Pulse Pressure but not Cardiac Diastolic Dysfunction on Intraoperative
history and examination needs to be performed looking Hemodynamic Instability. Journal of anaesthesia and clinical research.
2011;2:114.
for evidence of coronary artery disease, cerebrovascular
16. Zweifler, AJ, Shahab, ST. Pseudohypertension: A New Assessment.
disease and renal dysfunction. If not already done these
Journal of Hypertension. 1993 Jan;11(1):1-6.
patients require an ECG, urea and electrolytes with a
17. Kaplan NM et al. Perioperative management of hypertension. WWW.
calculated GFR and a urinalysis. The decision to cancel uptodate.com. Topic last up dated June 27th. 2013.
the surgery for blood pressure control should then come 18. Devereaux PJ, Yang H, Yusuf S et al. Effects of extended-release
with the recommendation that surgery be delayed for metoprolol succinate in patients undergoing non-cardiac surgery
a period of four to six weeks, so that the flow/pressure (POISE trial): a randomised controlled trial. Volume 371, Issue 9627, 31
May6 June 2008:18391847.
autoregulation of the major organ systems can normalise
19. Wax DB, Porter SB, Lin HM, et al. Association of preanaesthesia
again. The rapid control of blood pressure immediately
hypertension with adverse outcomes. J Cardiothoracic Vasc A.
prior to surgery is not recommended in the elective surgery 2010;24;6:927-930.
patient as this can lead to inadvertent hypo-perfusion of 20. Varon J, Marik P. Perioperative hypertension management. Vascular
the major organ systems during anaesthesia. Health Risk Management. 2008;3:615627.

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