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LETTER TO EDITOR
Year : 2018  |  Volume : 45  |  Issue : 2  |  Page : 110

Preoperative management of hypertension


Department of Medicine, Jawaharlal Nehru Medical College, KLE University of Higher Education and Research, Belagavi, Karnataka, India

Date of Web Publication10-Dec-2018

Correspondence Address:
Jayaprakash Shivalingappa Appajigol
Department of Medicine, Jawaharlal Nehru Medical College, KLE University of Higher Education and Research, Belagavi, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jss.JSS_57_18

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How to cite this article:
Shivalingappa Appajigol J. Preoperative management of hypertension. J Sci Soc 2018;45:110

How to cite this URL:
Shivalingappa Appajigol J. Preoperative management of hypertension. J Sci Soc [serial online] 2018 [cited 2019 Mar 19];45:110. Available from: http://www.jscisociety.com/text.asp?2018/45/2/110/247161



Sir,

The primary objective of preoperative evaluation is to detect unrecognized risk factors and diseases that may affect morbidity and mortality and to propose strategies to modify these risk factors and diseases. Elevated blood pressure (BP) is one of the common medical problems encountered while evaluating a patient before surgery. Untreated hypertension can produce many complications such as congestive heart failure, cerebrovascular diseases, coronary artery diseases, and renal impairment.[1] The level of risk relies upon the severity of hypertension. Furthermore, there is no strong evidence to suggest that postponing surgery to control BP will lead to reduced cardiac risk.[2] A diastolic pressure over 110 mmHg preoperatively is associated with complications, such as arrhythmias, myocardial ischemia and infarction, neurologic complications, and renal failure.[1] Perioperative adverse cardiac outcome significantly increases when hypertension is associated with end-organ diseases such as congestive heart failure and renal insufficiency.

There are many unanswered questions regarding the safe level of preoperative BP, perioperative use of beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blocker (ARB), and discontinuation of antihypertensive agents.

The latest hypertension guideline from the ACC/AHA and other partnering societies and European Society of Hypertension (ESH) and the European Society of Cardiology (ESC) has completely changed the thresholds to diagnose and treat hypertension.[3],[4] Following are the major recommendation from 2018 ESC/ESH and 2017 ACC/AHA guidelines for preoperative management of hypertension.

  1. In patients with hypertension undergoing planned elective major surgery, it is reasonable to continue medical therapy for hypertension until surgery
  2. Noncardiac surgery may not be deferred in patients with systolic BP <180 mmHg and diastolic BP <110 mmHg
  3. In patients with hypertension undergoing major surgery who have been on beta-blockers chronically, beta-blockers should be continued
  4. For patients undergoing surgery, abrupt preoperative discontinuation of beta-blockers or clonidine is potentially harmful
  5. Beta-blockers should not be started on the day of surgery in beta-blocker–naïve patients
  6. In patients with hypertension undergoing major surgery, discontinuation of ACE inhibitors or ARBs perioperatively may be considered
  7. Newly diagnosed hypertensive patients who are scheduled for elective surgery should be preoperatively screened for hypertension-mediated organ damage and cardiovascular risk
  8. Avoid large perioperative BP fluctuations during the perioperative period. Untreated hypertension can cause a variety of cardiovascular responses that potentially increase the risk of surgery. Therefore, it is important to optimize BP before the procedures.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wolfsthal SD. Is blood pressure control necessary before surgery? Med Clin North Am 1993;77:349-63.  Back to cited text no. 1
    
2.
Casadei B, Abuzeid H. Is there a strong rationale for deferring elective surgery in patients with poorly controlled hypertension? J Hypertens 2005;23:19-22.  Back to cited text no. 2
    
3.
Whelton PK, Carey RM, Aronow WS, Casey DE Jr., Collins KJ, Dennison Himmelfarb C, 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. J Am Coll Cardiol 2018;71:2199-269.  Back to cited text no. 3
    
4.
Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, et al. 2018 ESC/ESH guidelines for the management of arterial hypertension. Eur Heart J 2018;39:3021-104.  Back to cited text no. 4
    




 

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