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Review Article

Systemic hypertension and non‑cardiac surgery

Address for correspondence: Satyajeet Misra

Dr. Satyajeet Misra, Department of Anaesthesiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
Department of
Anaesthesiology, All India
Institute of Medical Sciences, ABSTRACT
Bhubaneswar, Odisha, India.
E‑mail: misrasatyajeet@gmail.
Primary systemic hypertension affects 10%–25% of individuals presenting for surgery and
com
anaesthesia and constitutes an important cause of cancellation of elective surgeries. Much of
the fear stems from the fact that hypertension may lead to adverse perioperative outcomes.
Access this article online Although long‑standing hypertension increases the risk of stroke, renal dysfunction or major
Website: www.ijaweb.org adverse cardiovascular events, the same is usually not seen in the perioperative period if blood
pressure is <180/110 mmHg and this has been the overriding theme in the recent guidelines on
DOI: 10.4103/ija.IJA_377_17
perioperative blood pressure management. Newer concepts include isolated systolic hypertension
Quick response code
and pulse pressure hypertension that are increasingly used to stratify risk. The aim of this review
is to focus on the adult patient with chronic primary systemic hypertension posted for elective
non‑cardiac surgery and outline the perioperative concerns.

Key words: Anaesthesia, complications, hypertensive emergencies, hypertensive heart disease,

systemic hypertension

INTRODUCTION the MEDLINE: systemic hypertension and non‑cardiac

surgery; systemic hypertension and perioperative
Primary systemic hypertension is defined as persistent complications OR outcomes; systemic hypertension
(average of 2 or more readings on 2 or more occasions) and anaesthesia OR anesthesia; hypertensive
systolic blood pressure (SBP) >140 mmHg and/or emergencies AND anaesthesia OR anesthesia. Searches
diastolic blood pressure (DBP) >90 mmHg in adults, in were limited to articles in English.
the absence of any known precipitating cause.[1] With
changing lifestyles and an increasing older population, CLASSIFICATION OF HYPERTENSION
anaesthesiologists are likely to encounter more patients
with comorbid illnesses presenting for elective Various stages/grades of blood pressure have been
surgery. In the US, hypertension accounts for >30% of defined in several guidelines for risk stratification and
individuals >20 years, with increasing prevalence in management [Table 1].[1,5,6] Recent guidelines do not
older individuals (50% of individuals aged > 65 years) however consider the universal definition of blood
and a slight male:female preponderance.[2] In India, pressure >140/90 mmHg in all adults to determine the
the prevalence of hypertension is 28%–32% in the initiation of antihypertensive therapy.[6] The 8th report
urban population and 27.6% in the rural population.[3] of the Joint National Committee on Prevention,
Hypertension being mostly asymptomatic, there is an
Detection, Evaluation and Treatment of high blood
increased probability of diagnosing it during a routine
pressure suggests that antihypertensive treatment
pre‑operative assessment. Data from western countries
should be initiated in older individuals >60 years
reveal that the incidence of hypertension in
if the blood pressure is >150/90 mmHg with a goal
pre‑operative patients ranges from 10% to 25%.[4]
Secondary hypertension is when the elevations in
This is an open access article distributed under the terms of the Creative
blood pressure can be attributed to a known cause, Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows
such as pregnancy‑induced hypertension, coarctation others to remix, tweak, and build upon the work non‑commercially, as long as the
of aorta, renal artery stenosis or phaeochromocytoma, author is credited and the new creations are licensed under the identical terms.

and is outside the scope of this review. For reprints contact: [email protected]

Articles used as references in this review were How to cite this article: Misra S. Systemic hypertension and non-
searched using a combination of the following terms in cardiac surgery. Indian J Anaesth 2017;61:697-704.

© 2017 Indian Journal of Anaesthesia | Published by Wolters Kluwer ‑ Medknow 697

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Misra: Systemic hypertension

Table 1: Definitions and classification of office blood larger conduit arteries are affected. In addition, the
pressure arterial stiffening leads to widening of the pulse
Category Systolic Diastolic pressure i.e., increased difference between the SBP
(mmHg) (mmHg)
Optimal <120 and <80
and DBP, due to systolic pressure summation and loss
Normal 120-129 and/or 80-84 of diastolic augmentation.[9] The augmented systolic
High normal 130-139 and/or 85-89 pressures impose an increased afterload on the heart
Grade 1 hypertension 140-159 and/or 90-99 which results in compensatory hypertrophy of the
Grade 2 hypertension 160-179 and/or 100-109 myocardium to minimise the wall stress (Laplace’s
Grade 3 hypertension >180 and/or >110
law). Loss of diastolic augmentation leads to decreased
Isolated systolic hypertension >140 and <90
Blood pressure is defined by the highest level, whether systolic or diastolic.
coronary perfusion since coronary perfusion pressure
Isolated systolic hypertension should be Graded 1, 2 or 3 according to systolic is equal to the difference of the DBP and the left
values in the ranges indicated. Reproduced with permission from reference 1
ventricular end‑diastolic pressure. Therefore, not only
the myocardial oxygen demand is increased due to
of reduction to <150/90 mmHg; whereas in younger
myocardial hypertrophy, but the supply is also reduced
individuals aged 18–59 years, antihypertensive
due to decreased coronary perfusion, especially the
treatment should be initiated if the blood pressure
sub‑endocardial perfusion which chiefly takes place
is >140/90 mmHg with a goal to reduce the pressure
during diastole.[9]
below this level.[6] These recommendations have not
been universally accepted by other societies such Untreated chronic hypertension may lead to myocardial
as the American Heart Association which are due ischaemia and/or infarction.[9,10] Ultimately, both
to come out with their own guidelines very soon. diastolic and systolic performance of the left ventricle
However, most of these guidelines are for ambulatory decline over time and may result in congestive
blood pressure management in the community with heart failure.[9,10] A subset of patients with diastolic
very few devoted specifically to perioperative high dysfunction may progress to isolated diastolic heart
blood pressure management. failure with preserved left ventricular ejection fraction.
Even asymptomatic diastolic dysfunction is associated
PERIOPERATIVE CONCERNS with a greater risk for adverse cardiovascular events
following high‑risk surgery.[9] Hypertension is also
For the anaesthesiologist, there are two main concerns:
associated with diabetes, dyslipidaemia and obesity
Should the diagnosis or detection of hypertension lead which are known risk factors for the development of
to further testing and/or postponement of the planned coronary artery disease.[10]
surgery and if surgery does proceed, what would be
the expected outcome of the patient’s perioperative Cerebrovascular system
journey? Although long‑standing hypertension is a Hypertension is a risk factor for ischaemic and
major risk factor for stroke, myocardial infarction, haemorrhagic brain injury.[2] Abrupt increases in the
congestive heart failure, renal and peripheral vascular blood pressure can lead to stroke due to intracerebral
disease, it is less clear whether elevated blood bleed. There may be luminal narrowing of carotid
pressure constitutes an increased perioperative risk;[7] arteries due to atherosclerosis which may lead to flow
and yet, uncontrolled hypertension constitutes a insufficiency. In addition, because the auto‑regulation
major reason for cancellation of elective surgeries.[8] shifts to the right in hypertensives, any degree of
A thorough understanding of the disease process, its hypotension would reduce the cerebral blood flow
influence on perioperative outcomes and knowledge leading to worsening of cerebral ischaemia. Studies
of best evidence and practice is imperative to facilitate have shown a history of stroke to be a predictor of
decision‑making and optimise the management of adverse perioperative cardiovascular events.[11]
such patients presenting for elective surgeries.
Renal system
IMPACT OF CHRONIC HYPERTENSION ON ORGAN Chronic renal insufficiency is a common sequelae
FUNCTION of hypertension and leads to a decrease in the
performance of kidneys. In the revised cardiac risk
Cardiovascular system index, a pre‑operative serum creatinine >2.0 mg/dl
Chronic hypertension leads to loss of arterial elasticity is identified as an independent factor that predicts
and compliance, and both smaller arterioles and increased cardiovascular risk.[12]

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Misra: Systemic hypertension

DOES HYPERTENSION INCREASE THE 10 mg of intranasal nifedipine and proceeded to

PERIOPERATIVE CARDIOVASCULAR RISK IN A surgery. The frequency of perioperative hypotension,
PATIENT UNDERGOING SURGERY? hypertension, brady‑ and tachy‑arrhythmias was
similar between the two groups, and there was no
Given the fact that there is a linear association cardiovascular or neurological complication in either
between hypertension and cardiovascular risk in the group.[13] Although the study drew several criticisms
community, the same association should be expected including absence of blinding, prolonged study
to naturally extrapolate to the perioperative scenario, duration (>9 years) and no evaluation of systolic
more so, since there are profound haemodynamic hypertension, it implies that patients without evidence
perturbations due to the stresses of anaesthesia and of significant co‑existing cardiovascular disease can
surgery. Surprisingly, however, there is no clear be taken up for surgery even with elevated blood
evidence that hypertension, in itself, constitutes a pressures on the day of surgery.
major risk factor for adverse perioperative cardiac
events or stroke in the adult population undergoing The American College of Cardiology and the American
elective non‑cardiac surgery. Heart Association list ‘uncontrolled systemic
hypertension’ as a minor predictor that has not been
Howell et al.[7] performed a meta‑analysis to evaluate shown to independently increase perioperative risk.[14]
the effect of hypertension on composite 30‑day Similarly, recent guidelines from the Association of
perioperative adverse cardiovascular events following Anaesthetists of Great Britain and Ireland and the
surgery. Although the odds ratio for an adverse British Hypertension Society state that in the absence
cardiovascular event in the analysis was 1.31 which of organ damage, blood pressure <180/110 mmHg does
was statistically significant, more importantly, this was not warrant cancellation or deferment of elective cases
not deemed to be a clinically significant finding. The in an attempt to optimise the blood pressure.[15] The
findings were further tempered by the fact that there recommendations of the guidelines are as follows:[15]
was much heterogeneity of the included studies. Thus, a. If the documented blood pressure in primary
the authors concluded that there is very little evidence care is <160/100 mmHg with or without optimal
of admission blood pressures <180/110 mmHg antihypertensive treatment in the last 1 year, then
causing any adverse perioperative complications. In further measurements and assessments need not
other words, there is little benefit to be obtained by be performed in the pre‑anaesthetic clinic (PAC)
deferring or cancelling elective surgeries if the blood b. In case no documented blood pressure
pressure is <180/110 mmHg. readings are available, then blood pressure
can be measured in the PAC. Any measured
There appears to be a small increase in the incidence blood pressure <180/110 mmHg without
of perioperative major cardiovascular adverse events evidence of organ damage can be cleared
in the presence of hypertension with organ damage, or for surgery without the need for further
with blood pressure >180/110 mmHg, but it is not clear assessment. Evidence of organ damage includes
whether postponing surgery to reduce blood pressure electrocardiography (ECG) changes, a history
reduces the rate of this complication.[7] Weksler of transient ischaemic attacks and/or stroke or
et al.[13] studied 989 treated chronic hypertensives raised serum creatinine. Additional testing is
scheduled for elective non‑cardiac surgery, with DBP rarely required (e.g., echocardiography) unless
of 110–130 mmHg on day of surgery, but without any the patient is undergoing a high‑risk surgery
evidence of target organ damage or disease such as such as vascular surgery
previous myocardial infarction or history of coronary c. The higher allowable blood pressure measured
revascularisation, unstable or severe angina pectoris, in PAC is because many patients can
left ventricular hypertrophy, renal failure, aortic develop ‘white coat’ hypertension in stressful
stenosis, pregnancy‑induced hypertension, any active surroundings. In addition, it takes years and
cardiac conditions or stroke. decades of blood pressure control to reduce
target organ damage and there is no evidence
Patients were randomised into control and treatment that acute perioperative reduction of blood
arms; the control group had their surgery postponed pressure confers any advantage in reduction of
and remained in hospital to optimise blood pressures adverse cardiovascular events beyond 1 month
before surgery whereas the treatment group received in primary care.

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The guidelines are less clear as to what to do with patients with ‘white coat hypertension’ is no different
patients with blood pressures of >180/110 mmHg than that of normotensives.[23]
or those with evidence of organ damage, obviously
because there is a paucity of studies exploring such PRE‑OPERATIVE EVALUATION
high blood pressures and perioperative outcomes.
The guidelines suggest that due to limited evidence, Given the fact that hypertension may be mostly
the decision to proceed with surgery in this subset of silent and first detected in the PAC, a blood pressure
patients should look at other factors such as associated of <180/110 mmHg in a patient scheduled for
comorbidities, functional class of the patient and non‑cardiac surgery and without evidence of organ
urgency of the surgery.[15] damage should not constitute a ground for referral,
postponement or cancellation of same‑day surgery. If
Much of the thinking that hypertension is associated investigations such as ECG or serum creatinine are not
with adverse perioperative outcomes comes from available, it may be prudent to consider obtaining and
a study by Prys‑Roberts et al.,[16] wherein they evaluating the same before proceeding for surgery.
demonstrated increased cardiovascular lability and
greater risk of perioperative myocardial ischaemia If the pre‑anaesthetic check‑up occurs a few days
in patients with poorly controlled hypertension. It is before planned surgery, the primary detection of raised
important to understand that most of the patients in blood pressure (>140/90 mmHg) represents a unique
their study had blood pressure consistent with Stage 3 opportunity to initiate antihypertensive treatment in
hypertension. In fact, hypertension during that period this subset of patients, though it is not clear whether
was classified by virtue of DBP i.e., DBP >95 mmHg. such short‑term treatment confers any advantage in
Normotensive patients in the Prys‑Roberts study,[16] reducing perioperative adverse cardiovascular events.
would currently fit into Stage 1 and 2 hypertension. The need for advanced cardiac testing would probably
Studies in Stage 1 and 2 hypertensive patients show be considered in the presence of poor or unknown
that there is no association between admission blood functional class, risk posed by surgery or presence
pressure and perioperative cardiac risk,[17,18] and this of associated comorbidities (diabetes mellitus, renal
is the spectrum of patients that anaesthesiologists are dysfunction), which increase the risk for coronary
mostly going to encounter in their practice. artery disease.

An important sub‑type of primary hypertension The mainstay of treatment is antihypertensive drugs,

is isolated systolic hypertension. Isolated systolic which apart from reducing blood pressure also induce
hypertension is defined as SBP >140 mmHg with reverse remodelling of the left ventricle, such as
DBP <90 mmHg, in adults, in the absence of any other regression of left ventricular hypertrophy, and confer
factors and is the most common sub‑type of elevated long‑term survival benefits.[24] The main class of
blood pressure in >2/3rd of individuals >50 years.[1,6] drugs include angiotensin‑converting enzyme (ACE)
DBP plateaus off by the 5th decade, and elevated SBP inhibitors, angiotensin receptor blockers (ARBs),
or a wide pulse pressure >80 mmHg may be more calcium channel blockers (CCBs), diuretics and
important risk factors for the development of adverse β‑blockers.
cardiovascular outcomes, including congestive cardiac
failure, higher incidence of fatal and non‑fatal strokes, Guidelines exist on how to initiate and maintain
coronary artery disease and renal dysfunction.[7,9,19] antihypertensive therapy, and interested readers
may refer these guidelines for a more detailed
Primary hypertension must be differentiated from description.[24] Briefly, patients <55 years should
‘white coat hypertension’, which is a physician be started on ACE inhibitors or a low‑cost ARB (if
measured blood pressure of >140/90 mmHg when ACE inhibitor is not tolerated or contraindicated).[24]
in fact the individual is normotensive (average blood Combination of these two agents should be avoided.
pressures <135/85 mmHg) and is due to environmental The much‑feared risks of intraoperative hypotension
stress.[20] An increased incidence of silent myocardial may be more prevalent in patients with heart failure
ischaemia has been seen in patients with ‘white coat and those receiving combination therapies with other
hypertension’ and is thought to justify treatment with antihypertensives,[25] and current literature suggests
antihypertensive medications,[21,22] though other studies continuing ACE inhibitors even perioperatively,
have shown that the long‑term rate of complications in especially if started for hypertension.[25‑27]

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Misra: Systemic hypertension

Patients >55 years should be offered a calcium hypertension, is associated with a higher mortality
channel blockers (CCB) or a thiazide diuretic if CCBs in hypertensive patients undergoing non‑cardiac
are not tolerated (e.g., oedema, heart failure or at risk surgery.[33] Even short periods of hypotension (mean
for heart failure). CCBs can be safely continued up arterial pressure <55 mmHg) have been associated
to the morning of surgery without significant risk of with myocardial and renal injury after non‑cardiac
hypotension.[24] Caution should be exercised, however, surgery.[34] This is not to imply that hypertensive
in patients who have heart failure or are hypovolaemic. surges should not be treated as Charlson et al.,[35]
have shown that hypertensive patients and diabetic
Diuretics may also be continued into the perioperative patients who had a cumulative 1 hour decrease
period, especially in patients who are diuretic in mean arterial pressure >20 mmHg or <1 hour
dependent (e.g., heart failure).[24] Patients on diuretics decrease of >20 mmHg and >15 minutes increase
may have hypokalaemia. Correction of potassium of >20 mmHg were at greatest risk for post‑operative
should be attempted over 24–48 h as rapid correction adverse events. Common causes of perioperative hypo
can precipitate arrhythmias due to increased and hypertension are listed [Table 2].[36]
transmembrane potassium gradients.[28]
No anaesthetic is superior to another though
β‑blockers are no more the preferred initial therapy sevoflurane has been reported to confer
for hypertension and are mainly reserved for cardioprotection and better haemodynamic stability
younger patients in whom there is intolerance as compared to propofol. It is important to maintain
or contraindication to ACE inhibitors or ARBs, an adequate depth of anaesthesia with monitoring
in women of child‑bearing potential, or in those such as bispectral index or end‑tidal minimum
patients with evidence of increased sympathetic anaesthetic concentration that allows appropriate
drive.[24] There is increased recognition that much titration of anaesthetic agents. Similarly, for spinal/
of the evidence for cardioprotection with β‑blockers epidural anaesthesia, one must avoid precipitous
may have been overstated since it was mainly seen and sudden fall of blood pressure. In general,
in high‑risk patients undergoing vascular surgery[29] since the lower limit of safe blood pressure in
and also possibly due to data fabrication.[30] Results hypertensive patients is unknown, it is advisable
from the POISE trial showed that though myocardial to keep the blood pressure within 20%–30% of
protection was better with β‑blockers, there was a baseline values.[37]
greater incidence of all‑cause mortality and stroke
if this was started acutely perioperatively.[31] This Table 2: Common causes of perioperative hypo and
hypertension
may be due to the fact that the hypotensive effect
Haemodynamic Causes
of untitrated doses might be worsened due to changes
anaesthesia, blood loss and profound inflammation Hypotension Systemic vasodilatation (general anaesthesia)
that occur during surgery. Furthermore, different Sympathetic blockade (spinal/epidural
anaesthesia)
β‑blockers behave differently as was demonstrated in
Hypovolaemia
the COMET trial where mortality was reduced with Blood loss
carvedilol compared with metoprolol in patients Mechanical ventilation
with chronic heart failure.[32] Drugs (Angiotensin receptor blockers)
Arrhythmias
ANAESTHETIC MANAGEMENT OF THE Acute coronary events
HYPERTENSIVE PATIENT Pulmonary thromboembolism (high risk
surgery for pulmonary thromboembolism and/
or patient predisposing factors)
Haemodynamic swings are more common and Hypertension Laryngoscopy and intubation
exaggerated in hypertensive patients as compared to Surgical stimulus
normotensives. Rightward shift of auto‑regulation Inadequate plane of anaesthesia and/or
analgesia
in hypertensive patients means that organ perfusion
Hypothermia
occurs at higher mean arterial pressures as Hypervolaemia
compared to normotensives, and thus, intraoperative Reversal and recovery
hypotension leads to hypoperfusion and target organ Hypoxia (postoperative)
damage during hypotension.[9] A retrospective study Indaquate analgesia (postoperative)
has found that intraoperative hypotension, but not Full bladder (postoperative)

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Although not specifically evaluated in hypertensive be urgently treated with the goal of blood pressure
patients, where possible, supraglottic airway devices reduction. Initial management should be to increase
such as laryngeal mask airway and its prototypes may the depth of anaesthesia and give additional analgesics;
be used because of less haemodynamic perturbations however, if this fails to resolve the hypertensive surges,
compared to laryngoscopy and intubation. then drugs that modify the vascular system may be
Hypertensive surges more >20% from baseline are used to reduce the blood pressure [Table 3],[36,38] with
associated with adverse outcomes[15] and should the goal being not >20%–25% reduction within the

Table 3: Drugs used for management of hypertensive surges/emergencies

Drug Class Intravenous dose Onset of Duration of Adverse effects Contraindications
action action
Esmolol Cardio‑selective 250-500 µg/kg bolus 2-10 min 10-30 min Unopposed Higher degrees of
β1‑receptor blocker dose over one min β‑blockade may lead heart block
followed by 50-100 to α‑storm Use with caution in
µg/kg/min for 4 min; asthmatics/COPD
repeat boluses for
further crises and
increase maximum
infusion dose to
300 µg/kg/min
Labetalol Combined α1 and Loading dose 20 5-10 min Single bolus Nausea Asthmatics
non‑selective β‑receptor mg; if crises not 2-4 min; Angioedema (rare) COPD
blocker; blood pressure controlled then repeated bolus Higher degrees of
reductions are achieved 20-80 mg bolus or infusion 2-6 h heart block
primarily by β‑blockade (every 10 min) or
since the α:β activity alternatively
is 1:7 2 mg/min infusion
Clevidipine Dihydropyridine type of 1-2 mg/h 2-4 min 5-15 min Non‑specific Allergic to soya or
CCB; highly selective Remaining solution egg products
for vascular smooth should be discarded Disorders of lipid
muscles after 24 h as it metabolism such as
promotes bacterial pancreatitis, lipoid
growth; maximum nephrosis
infusion rate is
32 mg/h
Nicardipine Dihydropyridine type of 5 mg/h; increase 5-15 min 4-6 h Non‑specific Severe aortic stenosis
CCB; highly selective by 2.5 mg/h every
for vascular smooth 5 min to maximum
muscles of 30 mg/h
Hydralazine Peripheral vasodilator Initial dose is 10 mg 10-30 min 2-6 h Vascular collapse CAD
slow intravenous Peripheral neuropathy Rheumatic MS
bolus, every 4-6 h Thrombocytopaenia SLE
as required; bolus
Volume overload
doses should not
exceed 20 mg
Sodium Nitric oxide donor; acts 0.3-0.5 µg/kg/min; Immediate 2-3 min Cyanide toxicity Raised ICP
nitroprusside on both arterial and avoid doses Chromaturia (red MI
venous smooth muscles >2 µg/kg/min urine)
Erythema
Nitroglycerin Venodilator 5 µg/min up to 2-5 min 5-10 min Headache ‑
maximum of Methaemoglobinaemia
20 µg/min
Enalaprilat Intravenous form of 0.625-1.25 mg initial 15-30 min 6-12 h Headache (awake Should be used in
enalapril dose; repeat doses patients) caution with
can be increased up Cough (awake Hypertrophic
to 5 mg maximum patients) cardio‑myopathy
Hyperkalaemia Severe aortic stenosis
Unstented renal
artery stenosis
Contraindicated in
pregnancy

Contd...

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Table 3: Contd...
Drug Class Intravenous dose Onset of Duration of Adverse effects Contraindications
action action
Fenoldopam Synthetic benzazepine 0.01-0.3 µg/kg/min 1-3 min 15-30 min Cardiac dysrhythmias Contains sodium
derivative which is as a continuous Dose‑dependent meta‑bisulphite
a partial D1 receptor infusion tachycardia which can cause
agonist anaphylactic reaction
May cause increase
in intraocular
pressure in patients
with glaucoma
COPD – Chronic obstructive pulmonary disease; CAD – Coronary artery disease; MS – Mitral stenosis; SLE – Systemic lupus erythematosus; ICP – Intracranial
pressure; MI – Myocardial infarction; CCB – Calcium channel blocker

first 30–60 minutes and gradual return to baseline is true of the patient presenting for surgery. Greater
over the next 24–48 hours. Metoprolol has been used understanding of the disease process and the fact that
in hypertension due to acute coronary syndromes, anaesthesiologists have better drugs and monitors at
but use in other settings is not well documented. their disposal to treat and evaluate the effects of such
Nifedipine can cause uncontrolled hypotension treatment has pushed the envelope continuously as
and reflex tachycardia and is not indicated in most to what constitutes a blood pressure which warrants
hypertensive crises. cancellation of elective non‑cardiac cases. It is not
merely the elevated blood pressure values, but what
Intra‑ and post‑operative monitoring are for the detection these values do to organs is what constitutes risk.
and treatment of haemodynamic swings in hypertensive A diabetic patient may be at a greater risk of myocardial
patients and to maintain the cardiac output. Invasive dysfunction with intraoperative blood pressures of
arterial blood pressure is usually not required unless 150/90 mmHg than an individual without any risk
the patient is undergoing a high‑risk surgery or has factors. Therefore, it is important to be careful but not
a hypertensive crisis which requires treatment with necessarily fearful, as care improves patient outcomes
vasoactive drugs. Similarly, central venous monitoring whereas fear results in unnecessary delays and case
is usually reserved for cases with expected significant cancellations.
fluid shifts or if inotropic support is anticipated and/
or required. Pulse contour algorithms‑based cardiac Financial support and sponsorship
output monitoring may not be reliable in hypertensive Nil.
patients as these algorithms are based on a normal
arterial compliance. Dynamic indices of preload such Conflicts of interest
as stroke volume and pulse pressure variation have not There are no conflicts of interest.
been validated in hypertensive individuals.[9]
REFERENCES
Transesophageal echocardiography is an excellent tool
to differentiate the cause of intraoperative hypotension, 1. Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A,
Böhm M, et al. 2013 ESH/ESC guidelines for the
but routine use is not indicated presently in patients, management of arterial hypertension: The Task Force for
including hypertensive patients undergoing the Management of Arterial Hypertension of the European
non‑cardiac surgery. Modalities which seek to evaluate Society of Hypertension (ESH) and of the European Society of
Cardiology (ESC). Eur Heart J 2013;34:2159‑219.
oxygen consumption and hence oxygen utilisation 2. Fleisher LA. Preoperative evaluation of the patient with
such as near‑infrared spectroscopy (NIRS) or mixed hypertension. JAMA 2002;287:2043‑6.
venous oximetry have largely not been evaluated 3. Anchala R, Kannuri NK, Pant H, Khan H, Franco OH,
Di Angelantonio E, et al. Hypertension in India: A systematic
in this subset of patients.[9] It would be interesting review and meta‑analysis of prevalence, awareness, and
to see whether NIRS can be used to define limits of control of hypertension. J Hypertens 2014;32:1170‑7.
auto‑regulation in organs at risk such as brain and 4. Varon J, Marik PE. Perioperative hypertension management.
Vasc Health Risk Manang 2008;4:615‑27.
kidneys in hypertensive individuals. 5. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA,
Izzo JL Jr., et al. The seventh report of the joint national
CONCLUSION committee on prevention, detection, evaluation, and
treatment of high blood pressure: The JNC 7 report. JAMA
2003;289:2560‑72.
Hypertension is a modifiable risk factor for 6. James PA, Oparil S, Carter BL, Cushman WC,
cardiovascular diseases and outcomes, and the same Dennison‑Himmelfarb C, Handler J, et al. 2014 evidence‑based

Indian Journal of Anaesthesia | Volume 61 | Issue 9 | September 2017 703

Page no. 15
[Downloaded free from http://www.ijaweb.org on Saturday, September 15, 2018, IP: 39.46.12.123]

Misra: Systemic hypertension

guideline for the management of high blood pressure in adults: Den Hond E, et al. Cardiovascular risk in white‑coat and
Report from the panel members appointed to the Eighth Joint sustained hypertensive patients. Blood Press 2002;11:352‑6.
National Committee (JNC 8). JAMA 2014;311:507‑20. 24. National Institute for Health and Care Excellence.
7. Howell SJ, Sear JW, Foëx P. Hypertension, hypertensive Hypertension in Adults: Diagnosis and Management. NICE
heart disease and perioperative cardiac risk. Br J Anaesth Clinical Guideline CG 127. Available from: http://www.nice.
2004;92:570‑83. org.uk/guidance/cg127. [Last accessed on 2017 May 11].
8. Hanada S, Kawakami H, Goto T, Morita S. Hypertension and 25. Reich DL, Hossain S, Krol M, Baez B, Patel P, Bernstein A,
anesthesia. Curr Opin Anaesthesiol 2006;19:315‑9. et al. Predictors of hypotension after induction of general
9. Lapage KG, Wouters PF. The patient with hypertension anesthesia. Anesth Analg 2005;101:622‑8.
undergoing surgery. Curr Opin Anaesthesiol 2016;29:397‑402. 26. Schulte E, Ziegler D, Philippi‑Höhne C, Kaczmarczyk G,
10. Spahn DR, Priebe HJ. Editorial II: Preoperative hypertension: Boemke W. Angiotensin‑converting enzyme inhibition and
Remain wary? “Yes” – Cancel surgery? “No”. Br J Anaesth blood pressure response during total intravenous anaesthesia
2004;92:461‑4. for minor surgery. Acta Anaesthesiol Scand 2011;55:435‑43.
11. Boersma E, Poldermans D, Bax JJ, Steyerberg EW, Thomson IR, 27. Höhne C, Meier L, Boemke W, Kaczmarczyk G. ACE inhibition
Banga JD, et al. Predictors of cardiac events after major does not exaggerate the blood pressure decrease in the
vascular surgery: Role of clinical characteristics, dobutamine early phase of spinal anaesthesia. Acta Anaesthesiol Scand
echocardiography, and beta‑blocker therapy. JAMA 2003;47:891‑6.
2001;285:1865‑73. 28. Wong KC, Schafer PG, Schultz JR. Hypokalemia and anesthetic
12. Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, implications. Anesth Analg 1993;77:1238‑60.
Polanczyk CA, Cook EF, et al. Derivation and prospective 29. Wijesundera DN, Duncan D, Nkonde‑Price C, Virani SS,
validation of a simple index for prediction of cardiac risk of Washam JB, Fleischmann KE, et al. Perioperative beta
major noncardiac surgery. Circulation 1999;100:1043‑9. blockade in noncardiac surgery: A systematic review for the
13. Weksler N, Klein M, Szendro G, Rozentsveig V, Schily M, 2014 ACC/AHA guideline on perioperative cardiovascular
Brill S, et al. The dilemma of immediate preoperative evaluation and management of patients undergoing noncardiac
hypertension: To treat and operate, or to postpone surgery? J surgery: A Report of the American College of Cardiology/
Clin Anesth 2003;15:179‑83. American Heart Association Task Force on practice guidelines.
14. Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, J Am Coll Cardiol 2014;64:2406‑25.
Fleischmann KE, et al. ACC/AHA 2007 guidelines on 30. Erasmus MC Follow‑up Investigation Committee. Report
perioperative cardiovascular evaluation and care for on the 2012 Follow‑up Investigation of Possible Breaches
noncardiac surgery: Executive summary: A Report of the of Academic Integrity; 2012. Available from: https://www.
American College of Cardiology/American Heart Association cardiobrief.files.wordpress.com/2012/10/integrity-rep
Task Force on Practice Guidelines (Writing committee to revise ort‑2012‑10‑english‑translation.pdf. [Last accessed on
the 2002 guidelines on perioperative cardiovascular evaluation 2017 Jul 12].
for noncardiac surgery): Developed in Collaboration with the 31. POISE Study Group, Devereaux PJ, Yang H, Yusuf S, Guyatt G,
American Society of Echocardiography, American Society Leslie K, et al. Effects of extended‑release metoprolol succinate
of Nuclear Cardiology, Heart Rhythm Society, Society of in patients undergoing non‑cardiac surgery (POISE trial): A
Cardiovascular Anesthesiologists, Society for Cardiovascular randomised controlled trial. Lancet 2008;371:1839‑47.
Angiography and Interventions, Society for Vascular Medicine 32. Poole‑Wilson PA, Swedberg K, Cleland JG, Di Lenarda A,
and Biology, and Society for Vascular Surgery. Circulation Hanrath P, Komajda M, et al. Comparison of carvedilol and
2007;116:1971‑96. metoprolol on clinical outcomes in patients with chronic
15. Hartle A, McCormack T, Carlisle J, Anderson S, Pichel A, heart failure in the Carvedilol or Metoprolol European
Beckett N, et al. The measurement of adult blood pressure Trial (COMET): Randomised controlled trial. Lancet
and management of hypertension before elective surgery: Joint 2003;362:7‑13.
Guidelines from the Association of Anaesthetists of Great 33. Monk TG, Bronsert MR, Henderson WG, Mangione MP,
Britain and Ireland and the British Hypertension Society. Sum‑Ping ST, Bentt DR, et al. Association between
Anaesthesia 2016;71:326‑37. intraoperative hypotension and hypertension and 30‑day
16. Prys‑Roberts C, Meloche R, Foëx P. Studies of anaesthesia in postoperative mortality in noncardiac surgery. Anesthesiology
relation to hypertension. I. Cardiovascular responses of treated 2015;123:307‑19.
and untreated patients. Br J Anaesth 1971;43:122‑37. 34. Walsh M, Devereaux PJ, Garg AX, Kurz A, Turan A,
17. Howell SJ, Sear YM, Yeates D, Goldacre M, Sear JW, Foëx P, Rodseth RN, et al. Relationship between intraoperative mean
et al. Risk factors for cardiovascular death after elective surgery arterial pressure and clinical outcomes after non‑cardiac
under general anaesthesia. Br J Anaesth 1998;80:14‑9. surgery: Toward an empirical definition of hypotension.
18. Goldman L, Caldera DL. Risks of general anesthesia and Anesthesiology 2013;119:507‑15.
elective operation in the hypertensive patient. Anesthesiology 35. Charlson ME, MacKenzie CR, Gold JP, Ales KL, Topkins M,
1979;50:285‑92. Shires GT, et al. Intraoperative blood pressure. What patterns
19. Aronson S, Boisvert D, Lapp W. Isolated systolic hypertension identify patients at risk for postoperative complications? Ann
is associated with adverse outcomes from coronary artery Surg 1990;212:567‑80.
bypass grafting surgery. Anesth Analg 2002;94:1079‑84. 36. Lonjaret L, Lairez O, Minville V, Geeraerts T. Optimal
20. Muscholl MW, Hense HW, Bröckel U, Döring A, Riegger GA, perioperative management of arterial blood pressure. Integr
Schunkert H. Changes in left ventricular structure and Blood Press Control 2014;7:49‑59.
function in patients with white coat hypertension: Cross 37. Kristensen SD, Knuuti J, Saraste A, Anker S, Bøtker HE,
sectional survey. BMJ 1998;317:565‑70. De Hert S, et al. 2014 ESC/ESA Guidelines on non‑cardiac
21. Nalbantgil I, Onder R, Nalbantgil S, Yilmaz H, Boydak B. The surgery: Cardiovascular assessment and management. The Joint
prevalence of silent myocardial ischaemia in patients with Task Force on non‑cardiac surgery: Cardiovascular assessment
white‑coat hypertension. J Hum Hypertens 1998;12:337‑41. and management of the European Society of Cardiology (ESC)
22. Sear JW. Perioperative control of hypertension: When will it and the European Society of Anaesthesiology (ESA). Eur J
adversely affect perioperative outcome? Curr Hypertens Rep Anaesthesiol 2014;31:517‑73.
2008;10:480‑7. 38. Vaughan CJ, Delanty N. Hypertensive emergencies. Lancet
23. Celis H, Staessen JA, Thijs L, Buntinx F, De Buyzere M, 2000;356:411‑7.

704 Indian Journal of Anaesthesia | Volume 61 | Issue 9 | September 2017

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