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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: lines@pixie.co.za

Abstract
The difficulty that anaesthetists face is that they often, when seeing a patient pre-operatively, do not have the benefit
of seeing the patient’s “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 world’s 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 world’s 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

S Afr Fam Pract 2014 S5 Vol 56 No 2 Supplement 1

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. showed a great variability amongst There is differing opinion as to the threshold value where anaesthetists as to which patients would be cancelled. treatment initiation and goals based on a single reading pre-operatively. detection. target of antihypertensive therapy. Without this consensus. Howell and of outcome. Until a more rational approach of an adverse peri-operative event. • The hypertensive patient who is over-medicated may while in the general black population.17-1.56). from Oxford. to have greater haemodynamic instability. acceptable limits to the anaesthetist.g. should be 140/90 mmHg. evaluation and light of such variation in practice. in 2001. 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. that there was an increased likelihood than any other condition. The benefits of treating isolated systolic and meta-analysis of 30 observational 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. 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.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. While diastolic blood pressure used to be the main patients during the early 1970s. or angiotensin receptor blocker (ARB). The latest Joint National This makes consensus protocols difficult to agree on. regardless of race or diabetes status. myocardial S Afr Fam Pract 2014 S6 Vol 56 No 2 Supplement 1 . initial therapy have a low blood pressure and or pulse rate. 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. College of Cardiology (ACC) do not support these • The hypertensive patient who has a raised blood guidelines. initial or add-on therapy surgery but the surgery is of an emergent nature. was 1. 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. it has now become in 1979. • The patient’s blood pressure is markedly raised before • In patients >18 years with CKD. start treatment in blood have been investigated or treated. should be a thiazide-type diuretic or CCB. calcium channel before for blood pressure control and now presents blocker (CCB). 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. cannot adequately be controlled. Anaesthetics Supplement: Hypertension and Anaesthesia Targets for treatment A survey published in the British Journal of Anaesthesia. or angiotensin converting enzyme having been on medication for only a few days. There was little evidence that. especially in the patient population above colleagues. The position is less to hypokalaemia in the mid-1980s. 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. by Dix and Howell. surgery and may make a diagnosis of hypertension • In patients <60 years. 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. the management of the elderly hypertensive patient may not be clear. pressures >150 mmHg systolic or >90 mmHg diastolic • The anaesthetist may see a patient immediately before and treat to under those thresholds.35 (95% CI 1. 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.7 Goldman and Caldera. One of the major areas of disagreement is pressure as a result of a medical condition e. did an extensive literature review 50 years of age. initial treatment • The patient may have been postponed a few days can be a thiazide-type diuretic. 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. anaesthetists routinely clear for patients with pressures above these levels. in the Committee on prevention. The difficulties faced by the anaesthetist relaxed treatment goals in the older population groups. • In non-black patients with hypertension.6 treatment needs to commence. should be an ACE inhibitor or ARB.8 More recently. 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. inhibitor (ACE).

Magnesium hospital the anaesthetist is in a better position to assess the sulphate. making cerebral colleagues implies that patients are more likely to die perfusion flow dependant. Carotid disease is also more common The major organs at risk from long standing. which leads to a decrease in coronary may also contribute significantly to intra-operative perfusion pressure. did however make effective correction for to unstable blood pressures. during severe hypotension. The heterogeneity of the limit myocardial perfusion. organ damage and evidence of associated cardiac. during surgical surgery to evaluate a patient’s fitness for surgery and stimulation and again at the end of the procedure during uncover potential risks. with excess catecholamine secretion and in this instance unnecessarily.8% help reduce the tendency to peri-operative ischaemia for the subgroup with baseline systolic pressures above and hence post-operative cardiac morbidity. A recent study did.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. 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. Anaesthetics Supplement: Hypertension and Anaesthesia ischaemia and arrhythmias. particularly. The review by Howell and autoregulation curve to the right. glyceryl trinitrate or magnesium sulphate can be the morning of surgery. making them vulnerable hypertension are the heart.20 Crucial to all of this is determining whether the hypertension occurs in isolation. immediately post induction. The vulnerable Management times peri-operatively are at the time of induction and The anaesthetist generally only has a short time before intubation. and its relation to anaesthesia than from the hypertension per se. Chronic hypertension leads to a shift in the cerebral renal and cerebral pathology.10 200 mmHg.13 becomes stiffer the left ventricular end diastolic pressure High pulse pressure hypertension (greater than 60 mmHg) (LVEDP) increases.3 Following pressures taken at different times over days or weeks. 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. as a bolus of four grams.3% and 2. induction. The diagnosis of hypertension used to control this response. untreated in patients with hypertension. and an increase in oxygen demand.3 An exaggerated pressor confounding variables very difficult. 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. 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). however. The overall incidence of adverse events (elevated follows that control of blood pressure pre-operatively may troponin levels or in-hospital death) was 1. Patients with stage 3 or greater surgery. it death. Subendocardial autoregulation studies analysed with regards the type of complications is also abnormal making hypertensive hearts vulnerable and likely risk. the kidneys and the brain. strokes and to supply and demand. 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. 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. 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. is probably the hypertension as they will have the benefit of ward blood safest and most effective first line treatment. if associated with haemodynamic instability. In patients who are already admitted to a beta blocker will be contra-indicated. As the muscle hypertrophies and significantly increase the risk of myocardial infarction. rhagic brain injury. as the pre-operative S Afr Fam Pract 2014 S7 Vol 56 No 2 Supplement 1 . 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. 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. 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. Medical funders do not allow extubation. Current evidence response may also occur during severe surgical stimulation would suggest. 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. so patients are only admitted on esmelol. custom years ago.15 intra-operative ischaemia and arrhythmias. and is supported by the ACA/AHA and extubation.

particularly in patients with known coronary elevated systolic blood pressure. It may also be reasonable to withhold arterial pressure. beta blockers. 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. Common causes of hypertension that need to pre-surgical blood pressure of greater than 140/90 mmHg be excluded are pain.17 markedly elevated preoperative pressures. Anti-hypertensive therapy should of studies providing good evidence for sound clinical in general be continued up until the day of surgery. These include thiazide diuretics. White coat hypertension is very relevant to anaesthetic Post-operative hypertension practice. as to which hypertensive patients need to be cancelled. 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. speciality Abrupt withdrawal of beta blockers may result in rebound back up and protocols. management. there is great variability between anaesthetists Chronic therapy may result in hypokalaemia.”2 S Afr Fam Pract 2014 S8 Vol 56 No 2 Supplement 1 . White coat hypertension is defined as an office/ is started.16 artery disease or those at risk of cerebrovascular accidents Anti-hypertensive agents or bleeding. These agents may blunt the compensatory activation of arrhythmias.20 combination of drugs for their hypertension. ventilatory challenges.11.4 These decisions may depend on the level of training of Beta blockers the anaesthetists as well as institutional facilities. led by SJ Howell. An appropriate anaesthetic technique to White coat hypertension control haemodynamic instability is required. 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. The levels at which intervention are required are ill Pseudo-hypertension (Osler’s sign) defined and will depend on the patient’s pre-operative status.” that patients are are no longer recommended to be started acutely in high not cancelled unnecessarily. Anaesthetics Supplement: Hypertension and Anaesthesia evaluation is a unique opportunity to identify patients Emergency surgery with hypertension and initiate appropriate treatment. a cerebral event and serious endocrine mmHg.18 The Sear and Foëx 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. were not able to show a a high blood pressure. ACEI/ARBs Such patients are more prone to peri-operative ischaemia. As with pre-operative hypertension.1 Studies have not shown an increase in long causes such as thyroid storm. especially in patients with pressure is low. but there is no the renin angiotensin system during surgery and result in clear evidence that deferring anaesthesia and surgery in prolonged hypotension. A thorough a period of weeks before the diagnosis of hypertension is investigation into the cause is mandatory before treatment made. Perioperative Ischaemic Evaluation Study (POISE). 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. Beta blockers this is to ensure that “no harm is done. 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. As was demonstrated in the survey done by Dix Thiazides and Howell. 12 be appropriate. get put on risk patients before surgery in the light of the published chronic treatment when it is not indicated. The position is less clear in patients with admission arterial pressures above this level. In 2004 Howell. phaeochromocytoma and term cardiovascular events to be any different from as a result of withdrawal of their long term anti-hypertensive normotensives. The purpose of articles such as hypertension and may precipitate angina. 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. general recommendations are difficult to make. angiotensin converting Recommendations and conclusion enzyme inhibitors (ACEI) or angiotensin II receptor blockers (ARBs) or calcium channel blockers (CCBs). peri-operative complications. 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. and worse still. all-cause mortality less than 180 mmHg systolic or 110 mmHg diastolic and and in particular stroke was increased. and cardiovascular lability. The Emergency surgery should not be delayed because of Oxford group.14 drugs. with an average daytime reading of less than 135/85 hypothermia. full bladder.

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Journal of anaesthesia and clinical research. 62: 107–14. other risks (diabetes. urea and electrolytes with a 17. cerebrovascular 16. patients do need treatment in the long term but it is 11. the surgery for blood pressure control should then come 18. Foëx P. Vascular the major organ systems during anaesthesia. O’Brien ET. A detailed Pulse Pressure but not Cardiac Diastolic Dysfunction on Intraoperative history and examination needs to be performed looking Hemodynamic Instability.