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Evaluation, risk stratification and management of hypertensive patients in the perioperative period

Published:October 09, 2019DOI:https://doi.org/10.1016/j.ejim.2019.09.012

      Highlights

      • Uncontrolled hypertension represents the main cause for postponing a non-cardiac surgery
      • There is a lack of evidence on how hypertensive patients should be perioperatively treated
      • There is a significant “white-coat effect” over the entire day before surgery as well as just before surgery
      • Preoperative assessment, including detailed medical history with emphasis on comorbidities, risk stratification and appropriate amendments in the previous therapeutic regimen, arewarranted.
      • An individualized approach is recommended

      Abstract

      Uncontrolled hypertension represents an important cause for postponing a non-cardiac surgery. Perioperative management of hypertensive patients should focus on cardiovascular risk stratification, evaluation of blood pressure levels and hypertension control, registration of the ongoing antihypertensive regimen and counseling about clinical decisions related to the expected perioperative blood pressure fluctuations. To date, there is a lack of evidence on how hypertensive patients should be perioperatively treated, while an empirical clinical approach is usually pursued in the usual practice. The present review appraises the gaps in the evidence and illustrates the current empirical approach of perioperative management of hypertension in non-cardiac surgery.

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      References

        • Williams B.
        • Mancia G.
        • Spiering W.
        • et al.
        2018 ESC/ESH guidelines for the management of arterial hypertension: the task force for the management of arterial hypertension of the European society of cardiology and the European society of hypertension.
        39. 2018https://doi.org/10.1097/HJH
        • Rapsomaniki E.
        • Timmis A.
        • George J.
        • et al.
        Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1·25 million people.
        Lancet. 2014; 383: 1899-1911https://doi.org/10.1016/S0140-6736(14)60685-1
        • Lawes C.M.
        • Vander Hoorn S.
        • Rodgers A.
        Global burden of blood-pressure-related disease, 2001.
        Lancet. 2008; 371: 1513-1518https://doi.org/10.1016/S0140-6736(08)60655-8
        • Lapage K.G.
        • Wouters P.F.
        The patient with hypertension undergoing surgery.
        Curr Opin Anaesthesiol. 2016; 29: 397-402https://doi.org/10.1097/ACO.0000000000000343
        • Vaishnava P.
        • Eagle K.A.
        The yin and yang of perioperative medicine.
        N Engl J Med. 2014; 370: 1554-1555https://doi.org/10.1056/NEJMe1402976
        • Howell S.J.
        Preoperative hypertension.
        Curr Anesthesiol Rep. 2018; 8: 25-31https://doi.org/10.1007/s40140-018-0248-7
        • Practice Advisory for Preanesthesia Evaluation
        Anesthesiology. 2012; 116: 522-538https://doi.org/10.1097/ALN.0b013e31823c1067
        • Glance L.G.
        • Lustik S.J.
        • Hannan E.L.
        • et al.
        The surgical mortality probability model.
        Ann Surg. 2012; 255: 696-702https://doi.org/10.1097/sla.0b013e31824b45af
        • Wolters U.
        • Wolf T.
        • Stützer H.
        • Schröder T.
        ASA classification and perioperative variables as predictors of postoperative outcome.
        Br J Anaesth. 1996; 77: 217-222https://doi.org/10.1093/bja/77.2.217
        • Girish M.
        • Trayner E.
        • Dammann O.
        • Pinto-Plata V.
        • Celli B.
        Symptom-limited stair climbing as a predictor of postoperative cardiopulmonary complications after high-risk surgery.
        Chest. 2001; 120: 1147-1151https://doi.org/10.1378/chest.120.4.1147
        • Fleisher L.A.
        • Fleischmann K.E.
        • Auerbach A.D.
        • et al.
        2014 ACC/AHA guideline on perioperative cardiovascular evaluation and Management of patients undergoing noncardiac surgery: executive summary.
        Circulation. 2014; 130: 2215-2245https://doi.org/10.1161/cir.0000000000000105
        • Kristensen S.D.
        • Knuuti J.
        • Saraste A.
        • et al.
        2014 ESC/ESA guidelines on non-cardiac surgery: cardiovascular assessment and management: the joint task force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA).
        Eur Heart J. 2014; 35: 2383-2431https://doi.org/10.1093/eurheartj/ehu282
        • Wijeysundera D.N.
        • Pearse R.M.
        • Shulman M.A.
        • et al.
        Assessment of functional capacity before major non-cardiac surgery: an international, prospective cohort study.
        Lancet. 2018; 391: 2631-2640https://doi.org/10.1016/S0140-6736(18)31131-0
        • Lee T.H.
        • Marcantonio E.R.
        • Mangione C.M.
        • et al.
        Prediction of cardiac risk of major noncardiac surgery.
        Circulation. 1999; 100: 1043-1049https://doi.org/10.1161/01.CIR.100.10.1043
        • Gupta P.K.
        • Gupta H.
        • Sundaram A.
        • et al.
        Development and validation of a risk calculator for prediction of cardiac risk after surgery.
        Circulation. 2011; 124: 381-387https://doi.org/10.1161/CIRCULATIONAHA.110.015701
        • Chambers J.B.
        Valve disease and non-cardiac surgery.
        Heart. 2018; : 1-10https://doi.org/10.1136/heartjnl-2017-312455
        • Kaw R.
        • Pasupuleti V.
        • Deshpande A.
        • Hamieh T.
        • Walker E.
        • Minai O.A.
        Pulmonary hypertension: an important predictor of outcomes in patients undergoing non-cardiac surgery.
        Respir Med. 2011; 105: 619-624https://doi.org/10.1016/j.rmed.2010.12.006
        • Kaw R.
        • Aboussouan L.
        • Auckley D.
        • et al.
        Challenges in pulmonary risk assessment and perioperative management in bariatric surgery patients.
        Obes Surg. 2008; 18: 134-138https://doi.org/10.1007/s11695-007-9282-0
        • James S.
        • Jhanji S.
        • Smith A.
        • O'Brien G.
        • Fitzgibbon M.
        • Pearse R.M.
        Comparison of the prognostic accuracy of scoring systems, cardiopulmonary exercise testing, and plasma biomarkers: a single-centre observational pilot study.
        Br J Anaesth. 2014; 112: 491-497https://doi.org/10.1093/bja/aet346
        • Howell S.J.
        • Sear J.W.
        • Föex P.
        Hypertension, hypertensive heart disease and perioperative cardiac risk.
        Br J Anaesth. 2004; 92: 570-583https://doi.org/10.1093/bja/aeh091
        • Kheterpal S.
        • O'Reilly M.
        • Englesbe M.J.
        • et al.
        Preoperative and intraoperative predictors of cardiac adverse events after general, vascular, and urological surgery.
        Anesthesiology. 2009; 110: 58-66https://doi.org/10.1097/ALN.0b013e318190b6dc
        • Crowther M.
        • van der Spuy K.
        • Roodt F.
        • et al.
        The relationship between pre-operative hypertension and intra-operative haemodynamic changes known to be associated with postoperative morbidity.
        Anaesthesia. 2018; 73: 812-818https://doi.org/10.1111/anae.14239
        • Koutsaki M.
        • Thomopoulos C.
        • Achimastos A.
        • et al.
        Perioperative SBP changes during orthopedic surgery in the elderly: clinical implications.
        J Hypertens. 2019; (April 3, ahead of print)https://doi.org/10.1097/HJH.0000000000002085
        • Schonberger R.B.
        • Nwozuzu A.
        • Zafar J.
        • et al.
        Elevated preoperative blood pressures in adult surgical patients are highly predictive of elevated home blood pressures.
        J Am Soc Hypertens. 2018; 12: 303-310https://doi.org/10.1016/j.jash.2018.01.012
        • Venkatesan S.
        • Myles P.R.
        • Manning H.J.
        • et al.
        Cohort study of preoperative blood pressure and risk of 30-day mortality after elective non-cardiac surgery.
        Br J Anaesth. 2017; 119: 65-77https://doi.org/10.1093/bja/aex056
        • Abbott T.E.F.
        • Pearse R.M.
        • Archbold R.A.
        • et al.
        Association between preoperative pulse pressure and perioperative myocardial injury: an international observational cohort study of patients undergoing non-cardiac surgery.
        Br J Anaesth. 2017; 119: 78-86https://doi.org/10.1093/bja/aex165
        • Sessler D.I.
        • Meyhoff C.S.
        • Zimmerman N.M.
        • et al.
        Period-dependent associations between hypotension during and for four days after noncardiac surgery and a composite of myocardial infarction and death: a substudy of the POISE-2 trial.
        Anesthesiology. 2018; 128: 317-327https://doi.org/10.1097/ALN.0000000000001985
        • Walsh M.
        • Devereaux P.J.
        • Garg A.X.
        • et al.
        Relationship between intraoperative mean arterial pressure and clinical outcomes after noncardiac surgery: toward an empirical definition of hypotension.
        Anesthesiology. 2013; 119: 507-515https://doi.org/10.1097/ALN.0b013e3182a10e26
        • van Lier F.
        • Wesdorp F.H.I.M.
        • Liem V.G.B.
        • et al.
        Association between postoperative mean arterial blood pressure and myocardial injury after noncardiac surgery.
        Br J Anaesth. 2018; 120: 77-83https://doi.org/10.1016/j.bja.2017.11.002
        • Asher D.I.
        • Avery E.G.
        The perioperative significance of systemic arterial diastolic hypertension in adults.
        Curr Opin Anaesthesiol. 2018; 31: 67-74https://doi.org/10.1097/ACO.0000000000000552
        • Hartle A.
        • McCormack T.
        • Carlisle J.
        • et al.
        The measurement of adult blood pressure and management of hypertension before elective surgery: joint guidelines from the association of anaesthetists of Great Britain and Ireland and the British hypertension society.
        Anaesthesia. 2016; 71: 326-337https://doi.org/10.1111/anae.13348
        • Whelton P.K.
        • Carey R.M.
        • Aronow W.S.
        • et al.
        2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: A report of the American College of cardiology/American heart association task force on clinical practice guidelines.
        Hypertension. 2018; 71: 1269-1324https://doi.org/10.1161/HYP.0000000000000066
        • Futier E.
        • Lefrant J.-Y.
        • et al.
        Effect of individualized vs standard blood pressure management strategies on postoperative organ dysfunction among high-risk patients undergoing major surgery.
        JAMA. 2017; 318: 1346https://doi.org/10.1001/jama.2017.14172
        • Auron M.
        • Harte B.
        • Kumar A.
        • Michota F.
        Renin-angiotensin system antagonists in the perioperative setting: clinical consequences and recommendations for practice.
        Postgrad Med J. 2011; 87: 472-481https://doi.org/10.1136/pgmj.2010.112987
        • Rosenman D.J.
        • McDonald F.S.
        • Ebbert J.O.
        • Erwin P.J.
        • LaBella M.
        • Montori V.M.
        Clinical consequences of withholding versus administering renin-angiotensin-aldosterone system antagonists in the preoperative period.
        J Hosp Med. 2008; 3: 319-325https://doi.org/10.1002/jhm.323
        • Turan A.
        • You J.
        • Shiba A.
        • Kurz A.
        • Saager L.
        • Sessler D.I.
        Angiotensin converting enzyme inhibitors are not associated with respiratory complications or mortality after noncardiac surgery.
        Anesth Analg. 2012; 114: 552-560https://doi.org/10.1213/ANE.0b013e318241f6af
        • Vijay A.
        • Grover A.
        • Coulson T.G.
        • Myles P.S.
        Perioperative management of patients treated with angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers: a quality improvement audit.
        Anaesth Intensive Care. 2016; 44: 346-352https://doi.org/10.1177/0310057X1604400305
        • Roshanov P.S.
        • Rochwerg B.
        • Patel A.
        • et al.
        Withholding versus continuing angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers before noncardiac surgery: an analysis of the vascular events in noncardiac surgery patIents cOhort evaluatioN prospective cohort.
        Anesthesiology. 2017; 126: 16-27https://doi.org/10.1097/ALN.0000000000001404
        • Lee S.M.
        • Takemoto S.
        • Wallace A.W.
        Association between withholding angiotensin receptor blockers in the early postoperative period and 30-day mortality: a cohort study of the veterans affairs healthcare system.
        Anesthesiology. 2015; 123: 288-306https://doi.org/10.1097/ALN.0000000000000739
        • Mudumbai S.C.
        • Takemoto S.
        • Cason B.A.
        • Au S.
        • Upadhyay A.
        • Wallace A.W.
        Thirty-day mortality risk associated with the postoperative nonresumption of angiotensin-converting enzyme inhibitors: a retrospective study of the veterans affairs healthcare system.
        J Hosp Med. 2014; 9: 289-296https://doi.org/10.1002/jhm.2182
        • Hollmann C.
        • Fernandes N.L.
        • Biccard B.M.
        A systematic review of outcomes associated with withholding or continuing angiotensin-converting enzyme inhibitors and angiotensin receptor blockers before noncardiac surgery.
        Anesth Analg. 2018; 127: 678-687https://doi.org/10.1213/ANE.0000000000002837
        • Twersky R.S.
        • Goel V.
        • Narayan P.
        • Weedon J.
        The risk of hypertension after preoperative discontinuation of angiotensin-converting enzyme inhibitors or angiotensin receptor antagonists in ambulatory and same-day admission patients.
        Anesth Analg. 2014; 118: 938-944https://doi.org/10.1213/ANE.0000000000000076
        • Drake T.M.
        • Cheung L.K.
        • Gaba F.
        • et al.
        Association between peri-operative angiotensin-converting enzyme inhibitors and angiotensin-2 receptor blockers and acute kidney injury in major elective non-cardiac surgery: a multicentre, prospective cohort study.
        Anaesthesia. 2018; 73: 1214-1222https://doi.org/10.1111/anae.14349
        • Legrand M.
        • Futier E.
        • Leone M.
        • et al.
        Impact of renin-angiotensin system inhibitors continuation versus discontinuation on outcome after major surgery: protocol of a multicenter randomized, controlled trial (STOP-or-NOT trial).
        Trials. 2019; 20: 1-7https://doi.org/10.1186/s13063-019-3247-1
        • Bradic N.
        • Povsic-Cevra Z.
        Surgery and discontinuation of angiotensin converting enzyme inhibitors: current perspectives.
        Curr Opin Anaesthesiol. 2018; 31: 50-54https://doi.org/10.1097/ACO.0000000000000553
        • Mangano D.T.
        • Layug E.L.
        • Wallace A.
        • Tateo I.
        Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery.
        N Engl J Med. 1996; 335: 1713-1720
        • Jørgensen M.E.
        • Hlatky M.A.
        • Køber L.
        • et al.
        Β-blocker-associated risks in patients with uncomplicated hypertension undergoing noncardiac surgery.
        JAMA Intern Med. 2015; 175: 1923-1931https://doi.org/10.1001/jamainternmed.2015.5346
        • Devereaux P.J.
        • Yang H.
        • Yusuf S.
        • et al.
        Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial.
        Lancet. 2008; 371: 1839-1847https://doi.org/10.1016/S0140-6736(08)60601-7
        • Bouri S.
        • Shun-Shin M.J.
        • Cole G.D.
        • Mayet J.
        • Francis D.P.
        Meta-analysis of secure randomised controlled trials of β-blockade to prevent perioperative death in non-cardiac surgery.
        Heart. 2014; 100: 456-464https://doi.org/10.1136/heartjnl-2013-304262
        • Bangalore S.
        • Wetterslev J.
        • Pranesh S.
        • Sawhney S.
        • Gluud C.
        • Messerli F.H.
        Perioperative β blockers in patients having non-cardiac surgery: a meta-analysis.
        Lancet. 2008; 372: 1962-1976https://doi.org/10.1016/S0140-6736(08)61560-3
        • Yang H.
        • Raymer K.
        • Butler R.
        • Parlow J.
        • Roberts R.
        The effects of perioperative β-blockade: Results of the Metoprolol after Vascular Surgery (MaVS) study, a randomized controlled trial.
        Am Heart J. 2006; 152: 983-990https://doi.org/10.1016/j.ahj.2006.07.024
        • Poldermans D.
        • Boersma E.
        • Bax J.J.
        • et al.
        The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery.
        N Engl J Med. 1999; 341: 1789-1794
        • Hajibandeh S.
        • Hajibandeh S.
        • Antoniou S.A.
        • Torella F.
        • Antoniou G.A.
        Effect of beta-blockers on perioperative outcomes in vascular and endovascular surgery: a systematic review and meta-analysis.
        Br J Anaesth. 2017; 118: 11-21https://doi.org/10.1093/bja/aew380
        • Blessberger H.
        • Kammler J.
        • Domanovits H.
        • et al.
        Perioperative beta-blockers for preventing surgery-related mortality and morbidity.
        Cochrane Database Syst Rev. 2018; : CD004476https://doi.org/10.1002/14651858.CD004476.pub3
        • Jørgensen M.E.
        • Andersson C.
        • Venkatesan S.
        • Sanders R.D.
        Beta-blockers in noncardiac surgery: did observational studies put us back on safe ground?.
        Br J Anaesth. 2018; 121: 16-25https://doi.org/10.1016/j.bja.2018.02.004
        • Weightman W.M.
        • Gibbs N.M.
        • Sheminant M.R.
        • Whitford E.G.
        • Mahon B.D.
        • Newman M.A.
        Drug therapy before coronary artery surgery: nitrates are independent predictors of mortality and beta-adrenergic blockers predict survival.
        Anesth Analg. 1999; 88: 286-291
        • Chung F.
        • Houston P.L.
        • Cheng D.
        • et al.
        Calcium channel blockade does not offer adequate protection from perioperative myocardial ischemia.
        Anesthesiology. 1988; 69: 343-347
        • Wijeysundera D.N.
        • Beattie W.S.
        • Rao V.
        • Karski J.
        Calcium antagonists reduce cardiovascular complications after cardiac surgery: a meta-analysis.
        J Am Coll Cardiol. 2003; 41: 1496-1505https://doi.org/10.1016/S0735-1097(03)00191-8
        • Lin Y.
        • Ma L.
        Blood pressure lowering effect of calcium channel blockers on perioperative hypertension.
        Medicine (Baltimore). 2018; 97e13152https://doi.org/10.1097/md.0000000000013152
        • Khan N.A.
        • Campbell N.R.
        • Frost S.D.
        • et al.
        Risk of intraoperative hypotension with loop diuretics: a randomized controlled trial.
        Am J Med. 2010; 123: 1059.e1-1059.e8https://doi.org/10.1016/j.amjmed.2010.07.019
        • Nishina K.
        • Mikawa K.
        • Uesugi T.
        • et al.
        Efficacy of clonidine for prevention of perioperative myocardial ischemia: a critical appraisal and meta-analysis of the literature.
        Anesthesiology. 2002; 96: 323-329
        • Wijeysundera D.N.
        • Naik J.S.
        • Beattie W.S.
        Alpha-2 adrenergic agonists to prevent perioperative cardiovascular complications: A meta-analysis.
        Am J Med. 2003; 114: 742-752https://doi.org/10.1016/S0002-9343(03)00165-7
        • Devereaux P.J.
        • Sessler D.I.
        • Leslie K.
        • et al.
        Clonidine in patients undergoing noncardiac surgery.
        N Engl J Med. 2014; 370: 1504-1513https://doi.org/10.1056/NEJMoa1401106
        • Duncan D.
        • Sankar A.
        • Beattie W.S.
        • Wijeysundera D.N.
        Alpha-2 adrenergic agonists for the prevention of cardiac complications among adults undergoing surgery.
        Cochrane Database Syst Rev. 2018; 2018https://doi.org/10.1002/14651858.CD004126.pub3
        • Bolliger D.
        • Seeberger M.D.
        • Lurati Buse G.A.L.
        • Christen P.
        • Gurke L.
        • Filipovic M.
        Randomized clinical trial of moxonidine in patients undergoing major vascular surgery.
        Br J Surg. 2007; 94: 1477-1484https://doi.org/10.1002/bjs.6012