© 2018 Kurt Pfeifer.

Hypertension (HTN)

ASSESSMENT

Data Gathering

History

Symptoms

  • Previous cardiovascular disease

  • Previous evaluation for secondary hypertension

  • History of hypertensive urgency/emergency

  • Orthopnea/nocturnal dyspnea

  • Chest pain

  • Exertional dyspnea or lightheadedness

  • Palpitations

  • Diaphoresis

  • Fatigue

  • Focal numbness/weakness

Exam

  • S4/S3

  • Pulmonary crackles

  • Edema

  • Elevated JVP

  • Cardiac murmurs

Risk Stratification

No well-validated perioperative risk stratification tools​ specific for hypertension have been developed. Risk stratification should be focused on optimal management of BP.

Diagnostic Studies

  • BMP within 4 months if non-low risk surgery and on antihypertensives which may alter renal function or electrolytes

MANAGEMENT

Indications for Surgical Delay

  • Elevated BP and signs of new end-organ damage

  • Elective surgery and severe hypertension (BP>180/110) (Hartle et al)

Medication Management

  • In general, all medications should be continued uninterrupted, with the following potential exceptions:

    • ACE inhibitors/ARBs:

      • Author prefers continuing these if preoperative BP is >140/90 and holding if not

      • Many anesthesiologists prefer withholding in all patients due to the potential for hypotension​ - determine the opinion of the anesthesiologists at your institution & if they favor holding these and your patient has poorly controlled HTN despite use of an ACE inhibitor or ARB, discuss with them if they would be willing to continue

      • Literature/guidelines are conflicting:

        • ACC/AHA & ESC guidelines both published in 2014. ACC/AHA gave IIa recommendation that continuation uninterrupted is reasonable, but if held before surgery, it is reasonable to resume as soon as possible after (based on evidence that failure to resume ACE inhibitors within 14 days and ARBs within 2 days increases 30-day mortality.) [Mudumbai et al & Lee et al]

        • ESC gave IIa recommendation that continuation uninterrupted is reasonable in stable patients with heart failure, but cessation 24 hours before surgery should be considered for patients taking an ACE inhibitor for HTN. Since then, a substudy of the VISION observational study found a significantly increased risk in stroke, mortality and MINS in patients who took an ACE inhibitor within 24 hours before surgery. [Roshanov et al

        • CCS guidelines published in 2017 recommended withholding ACEi/ARB 24 hours before noncardiac surgery and restarting ACEI/ARB on day 2 after surgery, if the patient is hemodynamically stable.

        • Since the publication of the CCS guidelines, an RCT of holding vs continuing ACEi/ARB was published and showed increased hypotension with continuation but no increase in major adverse outcomes. The study also showed increased severe hypertension from withholding ACEi/ARB. [Shiffermiller et al]

    • Neprilysin or renin inhibitors: author recommends managing these similarly to ACEi/ARB

    • Diuretics: if taken for severe CHF, continue uninterrupted; otherwise, author recommends withholding on morning of surgery, particularly in patients at risk for AKI

COUNSELING & COMMUNICATION

  • Educate patients with elevated BP that even though surgical delay may not be necessary, their long-term risk is increased, and they need follow-up