BJA Education, 21(11): 426e432 (2021)
doi: 10.1016/j.bjae.2021.07.002
Matrix codes: 1A02,
2A03, 3I00
Preoperative hypertension: perioperative
implications and management
A. Tait1 and S.J. Howell1,2,*
1
Leeds Teaching Hospitals NHS Trust, Leeds, UK and 2Leeds Institute of Medical Research at St James’s, St
James’s University Hospital, Leeds, UK
*Corresponding author: andrewtait@nhs.net, s.howell@leeds.ac.uk
Keywords: antihypertensive agents; hypertension; preoperative care
Learning objectives
By reading this article, you should be able to:
 Describe the management of patients with hy-
pertension presenting for surgery.
 Identify target organ damage associated with
hypertension.
 Discuss the perioperative management of pa-
tients with hypertension.
Systemic arterial hypertension is one of the most important
treatable causes of population morbidity and mortality. It is
common, affecting one in four adults in England (12.5 million),
with a further 5.5 million likely remaining undiagnosed, but
evidence to guide the preoperative optimisation of patients
with hypertension is limited.1,2 Of necessity, guidelines rely to
a considerable extent on observational data and the results of
studies in the non-operative setting. In the UK, the Associa-
tion of Anaesthetists (AoA) and the British Hypertension So-
ciety (BHS) have published a joint statement on the
management of perioperative hypertension, and more
recently, the Perioperative Quality Initiative (POQI) Consensus
Workgroup has provided guidance.3,4 The AoA/BHS guidance
suggests that surgery should be postponed if the patient’s
blood pressure is over 180/110 mmHg, whereas the more
Andrew Tait MBChB FRCA is a locum consultant at Leeds Teaching
Hospitals NHS Trust.
Simon Howell MA(Cantab) MRCP FRCA MSc MD is an associate
professor of anaesthesia at the University of Leeds and an honorary
consultant anaesthetist at Leeds Teaching Hospitals NHS Trust. He
is and editorial board member and director of the British Journal of
Anaesthesia.
Accepted: 1 July 2021
© 2021 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
For Permissions, please email: permissions@elsevier.com
Advance Access Publication Date: 15 September 2021
Key points
 High systemic arterial blood pressure in isolation
is not a reason to cancel elective surgery per se.
 Preoperative decisions should be made on each
patient’s overall cardiac risk rather than solely on
the blood pressure reading.
 Lower community thresholds for treatment will
lead to more patients being prescribed antihy-
pertensive pharmacotherapy.
 Combination tablets could complicate preopera-
tive management of antihypertensive
pharmacotherapy.
 Preoperative hypotension may have implications
for future preoperative risk stratification.
recent POQI consensus questions whether there is sufficient
evidence to recommend a specific blood pressure to decide on
whether to proceed with surgery or not. This review will up-
date the reader regarding changes in the guidelines for man-
agement of hypertension in the community and the
preoperative management of hypertensive medications. The
impact of preoperative, intraoperative and postoperative
blood pressure, and the importance of preoperative hyper-
tension and hypotension on postoperative outcome will be
discussed.
Long-term management and treatment of
hypertension
Treatment targets
The aim of chronic blood pressure management is lifetime
cardiovascular risk reduction, whereas perioperative blood
pressure management goals focus on the avoidance of peri-
operative morbidity and mortality. However, guideline
426

statements on the long-term management of hypertension
set the context for the perioperative management of blood
pressure.
The UK National Institute for Health and Care Excellence
(NICE) classification of hypertension is given in Table 1. The
diagnosis of stages 1 and 2 hypertension rests on the use of
ambulatory and home blood pressure monitoring initiated on
the basis of clinic blood pressure measurements (Fig. 1). Pa-
tients whose clinic blood pressure measurements are >140/
90 mmHg are offered ambulatory blood pressure monitoring
to confirm a diagnosis of hypertension. Ambulatory moni-
toring gives an average value for the blood pressure over the
monitoring period. The NICE guidance recommends formu-
lating an average from at least 14 blood pressure values taken
during waking hours. Home blood pressure monitoring can be
offered when ambulatory monitoring is not feasible. Patients
with stage 1 hypertension are offered lifestyle advice and may
receive pharmacological treatment based on their cardiovas-
cular disease risk. Patients with stage 2 hypertension are
offered pharmacological therapy alongside lifestyle advice.
Patients aged over 40 yrs who are diagnosed with hyperten-
sion should be considered for a specialist referral to exclude
secondary causes. Investigations to identify target organ
damage and quantify cardiovascular risk should commence
whilst awaiting diagnosis of suspected hypertension.
The 2019 NICE guidance increases the emphasis on main-
taining blood pressure consistently below target levels. Target
blood pressures in patients aged under 80 yrs are <140/
90 mmHg (clinic measurement) or <135/85 mmHg (ambula-
tory or home measurement). The target is slightly higher in
patients over 80 yrs at <150/90 mmHg (clinic measurement)
and <145/85 mmHg (ambulatory or home measurement).
Currently, it is estimated that only 50% of patients with hy-
pertension actually achieve clinic blood pressures below 140/
90 mmHg.5
The 2018 European Society of Cardiology/European Society
of Hypertension guidelines are more demanding than the
NICE guidelines with regard to blood pressure targets.5 They
advise that treatment should be initially targeted to reduce
blood pressures to below 140/90 mmHg and if tolerated
further to 130/80 mmHg, and state that in patients under 65
yrs the systolic blood pressure should be reduced to
120e129 mmHg.5 The European guidance also recommends
lower blood pressure targets in diabetics, whereas NICE
makes no distinction.
Both the UK and European guidelines advocate the use of
ambulatory blood pressure monitoring for diagnosing hyper-
tension. Ambulatory monitoring gives a better indication of
the ‘true’ blood pressure and correlates well with invasive
Table 1 Stages of hypertension described in the National
Institute for Health and Care Excellence (NICE) guidelines:
hypertension in adults: diagnosis and management. ABPM,
ambulatory blood pressure monitoring.6
Stage Clinic blood ABPM
pressure (mmHg) daytime average (mmHg)
1 140/90e159/99 135/85e149/94
2 160/100e179/119 >150/95
3 Systolic >180 or
diastolic >120
Preoperative hypertension
blood pressure measurements.6 It can identify white coat and
masked hypertension, and also provides additional informa-
tion on 24 h blood pressure variability.5 When available,
ambulatory monitoring gives a robust baseline pressure that
can be used to guide intraoperative care. Despite the cost of
equipment, ambulatory monitoring is likely to be the most
cost-effective method for diagnosing hypertension.6
Blood pressure management
Lifestyle
Appropriate lifestyle modifications should be suggested to
patients with suspected or confirmed hypertension.6 Such
management rests on establishing an effective collaboration
between the patient, the doctor and other healthcare staff.7
Advice includes weight loss, healthy eating, smoking cessa-
tion, increased physical activity and reduced alcohol con-
sumption. Some patients with stage 1 hypertension can delay
or avoid the need for pharmacotherapy by following this
advice. However, most patients with hypertension will
require drug treatment, and this should not be delayed in
patients with a high cardiovascular risk or related organ
damage.5
Pharmacotherapy
In the UK, NICE recommends pharmacotherapy in patients
aged <80 yrs with stage 1 hypertension together with target
organ damage, cardiovascular disease, renal disease, diabetes
or 10 yrs CVD risk of >10%. The guidance was updated in 2019
with a major change that pharmacological treatment is now
offered to patients with stage 1 hypertension under the age of
80 who have 10 yrs cardiovascular risk of >10%, a reduction
from the previous 20% threshold.6 This equates to an addi-
tional 450,000 men and 270,000 women being eligible for
treatment.8 It is important to mention that under the NICE
guidelines, patients aged under 80 yrs with systolic blood
pressures <139 mmHg would not be offered treatment
regardless of cardiovascular risk.8
With more people being eligible for treatment and greater
emphasis on tight blood pressure control, the number of pa-
tients taking antihypertensive therapy presenting for surgery
may increase significantly.
The recommended tool for cardiovascular risk calculation
in the UK is currently the QRISK3 calculator (https://qrisk.org/
three/),9 which incorporates a number of variables, such as
mental health and corticosteroid use, not included in the
previously used QRISK2 calculator. The European guidance
uses the Systemic Coronary Risk Evaluation score. It uses
fewer variables than the QRISK3 calculator and is also avail-
able online (https://www.heartscore.org/).10 The American
College of Cardiology uses the Atherosclerotic Cardiovascular
Disease score (https://tools.acc.org).11
For patients over 80 yrs of age, NICE advises considering
starting drug treatment at blood pressures >150/90 mmHg.
The UK NICE guidance recommends a stepwise approach to
commencing antihypertensive therapy and highlights that
compliance with treatment must be explored before
commencing another drug class. There are various treatment
options at each step to allow for intolerance of particular
treatments, as detailed in Figure 2.
In Europe, combination pills are recommended. This is
based on the premise that monotherapy is often ineffective in
achieving target blood pressures of below 130/80 mmHg, as
recommended in the European guidelines, and most patients
BJA Education - Volume 21, Number 11, 2021 427
Preoperative hypertension

Hypertension in adults: diagnosis and treatment

Offer lifestyle advice and continue to offer it periodically

Clinic BP ABPM or HBPM Use clinical judgement for people with frailty or multimorbidity

• Check BP at least every 5 years and more often if clinic BP close

Under Check BP at least every 5 years and Under
to 140/90 mmHg
140/90 mmHg more often if close to 140/90 mmHg 135/85 mmHg
• If evidence of target organ damage, consider alternative causes

Offer lifestyle advice. Discuss the person's

In addition, for the following groups: CVD risk and
Age >80 with clinic BP >150/90 mmHg: preferences for
• Consider drug treatment treatment, including
Age <80 with target organ damage, no treatment.
CVD, renal disease, diabetes or See NICE's patient
• Offer ABPM (or HBPM if ABPM is 10-year CVD risk ≥10%: decision aid for
135/85 to • Discuss starting drug treatment hypertension
140/90 to declined or not tolerated)
149/94 mmHg Age <60 with 10-year CVD risk <10%: See next page for
179/119 mmHg • Investigate for target organ damage
(Stage 1) • Consider drug treatment choice of drug,
• Assess cardiovascular risk
Age <40: monitoring and BP
• Consider specialist evaluation of targets.
Assess for target organ damage as secondary causes and assessment • Offer annual review
soon as possible: long-term benefits and risks of • Support adherence
• Consider starting drug treatment treatment to treatment
immediately without ABPM/HBPM if
target organ damage
• Repeat clinic BP in 7 days if no target Offer lifestyle advice and drug treatment
organ damage Age <40:
150/95 mmHg
180/120 mmHg • Consider specialist evaluation of
or more
or more secondary causes and assessment
Refer for same-day specialist review if: (Stage 2)
long-term benefits and risks of
• retinal haemorrhage or papilloedema
treatment
(accelerated hypertension) or
• Iife threatening symptoms or
• suspected pheochromocytoma

Fig 1 Visual summary of the UK National Institute for Health and Care Excellence (NICE) recommendations for diagnosing and treating hypertension; hyper-
tension in adults: diagnosis and treatment. Reproduced with permission from reference 6. ABPM, ambulatory blood pressure monitoring; CVD, cardiovascular
disease; HBPM, home blood pressure monitoring.

will therefore require combination therapy. Combination pills
are single pills that contain two or three drugs or drug classes,
such as an angiotensin-converting enzyme inhibitor (ACEI),
calcium channel blocker and a diuretic. These may be only
available in certain jurisdictions. Combination therapy can be
quicker and more effective at reducing blood pressure than
up-titrating monotherapy, and also improves treatment
compliance.5 Whilst being useful at managing hypertension,
combination tablets may pose a challenge in the perioperative
period if one drug class is to be stopped and another
continued.
Preoperative implications of hypertension
History and investigation
Hypertension is generally asymptomatic and may be picked
on routine blood pressure screening or during the clinical
assessment for another condition or for planned surgery.12
Patients with hypertension can also present with papil-
loedema, new onset confusion, chest pain, signs of heart
failure or acute kidney injury. Same-day specialist review
should be sought in symptomatic patients with blood pres-
sures >180/120 mmHg.6 Clinical review of the hypertensive
patient should encompass assessment of overall cardiovas-
cular risk and of the comorbidities for which hypertension is a
risk factor.
Target organ damage and ‘hypertension-mediated organ
dysfunction’ are terms often used to describe the
pathologies associated with hypertension, such as renal
impairment and cardiovascular and cerebrovascular dis-
eases. Preoperative investigations of patients with diag-
nosed hypertension or raised blood pressure should be
aimed at identifying and assessing these conditions. Rec-
ommended investigations include serum electrolytes,
creatinine, estimated glomerular filtration rate, cholesterol,
a 12-lead electrocardiogram and urinalysis. Hypertension
and diabetes are associated; people with type 2 diabetes are
approximately two and a half times more likely to develop
hypertension. Measurement of glycosylated haemoglobin
gives an indication of long-term glucose control. The UK
NICE guidance also recommends fundoscopy to assess hy-
pertensive retinopathy. However, this procedure would
likely be impractical in the preoperative setting. Other pre-
operative investigations, such as echocardiography, should
be guided by clinical judgement and surgical risk.
Preoperative hypertension
Historically, elective surgery in patients with poorly
controlled blood pressure has been postponed because of
perceived increased perioperative cardiovascular risk. This
practice is based on older studies in patients who now would
be classed as having severe hypertension, and it is inappro-
priate to use data from these studies to guide management of
patients with stages 1 and 2 hypertension.13 An observational
cohort study revealed no association between the stage of
hypertension and significant haemodynamic instability,

428 BJA Education - Volume 21, Number 11, 2021

 Preoperative hypertension

Choice of antihypertensive drug1, monitoring treatment and BP targets

Hypertension with Hypertension without type 2 diabetes

Monitoring treatment
type 2 diabetes
Age <55 and not Black African or Use clinic BP to monitor treatment.
of black African or African-Caribbean Measure standing and sitting BP in
Age 55 or over people with:
African-Caribbean family origin

Use clinical judgement for people with frailty or multimorbidity

family origin (any age) • type 2 diabetes or

Offer lifestyle advice and continue to offer it periodically

• symptoms of postural hypotension or
• aged 80 and over.
Advise people who want to self
Step 1 ACEI or ARB2,3 CCB -monitor to use HBPM. Provide
training and advice.
Consider ABPM or HBPM, in addition
to clinic BP, for people with white-coat
CCB effect or masked hypertension.
ACEI or ARB2,3
+
Step 2 +
ACEI or ARB2,3 or
CCB or thiazide-like diuretic
thiazide-like diuretic
BP targets
Reduce and maintain BP to the
following targets:
Step 3 ACEI or ARB2,3 + CCB + thiazide-like diuretic Age <80 years:
• Clinic BP <140/90 mmHg
• ABPM/HBPM <135/85 mmHg
Age ≥80 years:
Confirm resistant hypertension: confirm elevated BP with ABPM or • Clinic BP <150/90 mmHg
HBPM, check for postural hypotension and discuss adherence • ABPM/HBPM <145/85 mmHg
Consider seeking expert advice or adding a: Postural hypotension:
Step 4 • low-dose spironolactone4 if blood potassium level is ≤4.5 mmol/l • Base target on standing BP
• alpha-blocker or beta-blocker if blood potassium level is >4.5 mmol/l Frailty or multimorbidity:
Seek expert advice if BP is uncontrolled on optimal tolerated • Use clinical judgement
doses of 4 drugs

1For women considering pregnancy or who are pregnant or breastfeeding, see NICE’s guideline on hypertension in pregnancy. For people with chronic kidney disease,
see NlCE’s guideline on chronic kidney disease. For people with heart failure. see NICE’s guideline on chronic heart failure
2See MHRA drug safety updates on ACE inhibitors and angiotensin-ll receptor antagonists; not for use in pregnancy, which states ‘Use in women who are planning pregnancy
should be avoided unless absolutely necessary, in which case the Potential risks and benefits should be discussed’. ACE inhibitors and angiotensin II receptot antagonists:
use during breastfeeding and clarification: ACE inhibitors and angiotensin II receptor antagonists. See also NlCE’s guideline on hypertension in pregnancy.
3Consider an ARB, in preference to an ACE inhibitor in adults of African and caribbean family origin.
4At the time of publication (August 2019), not all preparations of spironolactone have a UK marketing authorisation for this indication.

Fig 2 Visual summary of the UK National Institute for Health and Care Excellence (NICE) recommendations for diagnosing and treating hypertension; choice of
antihypertensive drug, monitoring and targets. Reproduced with permission from reference 6. ABPM, ambulatory blood pressure monitoring; ACEI, angiotensin-
converting enzyme inhibitor; ARB, angiotensin receptor blocker; CCB, calcium channel blocker; HBPM, home blood pressure monitoring.

although just 3% of the study group had stage 3 hypertension
(blood pressure >180/110 mmHg).14 There is insufficient evi-
dence to suggest that one value of either the systolic pressure,
diastolic pressure or MAP is superior at predicting risk.3
There is little evidence to suggest that lowering blood
pressure preoperatively reduces risk and that patients with
stage 1 or 2 hypertension without target organ damage have
increased perioperative morbidity and mortality.3,4
The AoA/BHS guidance advises that patients whose
blood pressure in the community is <160/100 mmHg may be
referred for elective surgery without delaying for further
investigation or treatment of their blood pressure.4 In pa-
tients who are referred for elective surgery without a
community blood pressure reading, surgery can proceed
provided that the blood pressure measurement in the pre-
assessment clinic is <180/110 mmHg. If the blood pressure
is >180/110 mmHg, the guidelines suggest that surgery
should ideally be delayed, allowing antihypertensive treat-
ment to be initiated.
Where hypertension has been identified de novo at a pre-
operative assessment clinic, there is a responsibility to
communicate this to the patient’s primary care practitioner.
The AoA/BHS guidance includes a draft letter that can be sent
to them.
In 2019, the multinational Perioperative Quality Consensus
multidisciplinary working group published a set of consensus
statements and practical recommendations on preoperative
blood pressure, risk and outcomes for elective surgery.3 These
recommendations suggest that, whilst extremes of blood
pressure may be associated with increased risk, there is no
evidence to identify a specific blood pressure value above
which would alter the decision whether to proceed with
surgery.3
Hypertension in the elderly
Hypertension is common in older patients, having a preva-
lence of over 60% in people aged >60 yrs.5 The European
guidelines define ‘old’ as patients >65 yrs and ‘very old’ as
those >80 yrs. There has previously been concern that anti-
hypertensive treatment in elderly patients may increase
mortality and morbidity if they have peripheral arterial dis-
ease or heart failure.15 Evidence from RCTs has demonstrated
that antihypertensive therapy in the old and very old signifi-
cantly reduces cardiovascular morbidity and all-cause mor-
tality, with the caveat that frail and institutionalised patients
have largely been excluded from such studies.5 The NICE
guidance advises that blood pressure treatment targets

BJA Education - Volume 21, Number 11, 2021 429

Preoperative hypertension

ACEI / ARB
Hold 24 hours preoperatively No evidence to lower high
and restart within 48 hours blood pressure immediately
after operation preoperatively
Blood pressure

Thiazide diuretic / Preoperative blood

Calcium channel blocker pressure values may
No evidence to stop be used to define
Loop diuretics perioperative blood
Consider per patient pressure targets

β Blocker
Continue when prescribed for
congestive heart failure Preoperative hypotension
or myocardial infarction may be associated with
Do not start preoperatively for increased risk
risk reduction

Preoperative period Induction

Fig 3 Infographic demonstrating the Perioperative Outcomes Quality Initiative (POQI) consensus recommendations on the management of blood pressure and
antihypertensive agents in the preoperative period. Reproduced with permission from POQI. ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin
receptor blocker.

should be higher (<150/90 mmHg) in patients aged > 80 yrs.
The guidance emphasises the importance of using clinical
judgement when deciding treatment targets in these groups.
Postural hypotension is more common in this group, and
these patients can be at increased risk of adverse events, such
as falls, if treatment is commenced based solely on seated
blood pressures. To screen for postural hypotension, seated
blood pressures should be compared with standing blood
pressures. If the standing systolic pressure decreases by more
than 20 mmHg, then this should prompt a review of medica-
tion or specialist referral to avoid adverse effects from anti-
hypertensive therapy.
Secondary hypertension
Hypertension resulting from an identifiable pathology is
referred to as secondary hypertension and accounts for 5e15%
of patients with hypertension.5 ‘Red flags’ include young pa-
tients with an absence of risk factors, sudden increases in
blood pressure in previously stable patients and resistant
hypertension. Common causes include obstructive sleep
apnoea, renal disease and endocrine abnormalities. Non-
urgent surgery should be delayed to enable these patients to
have further investigations.
Preoperative hypotension
Recent observational data suggest a significant association
between preoperative hypotension and increased mortality in
patients aged >65 yrs.2 A non-linear increase in postoperative
mortality was reported with systolic pressures <119 mmHg
and diastolic pressures <63 mmHg.2 To put the results in
context, the paper describes a preoperative systolic pressure
of 100 mmHg as having a similar risk to a preoperative diag-
nosis of heart failure.2
Preoperative management of antihypertensive drugs
In patients who are still taking ACEIs or angiotensin re-
ceptor blockers (ARBs), hypotension may be more profound
especially when in combination with diuretics.16 The 2017
Vascular events In noncardiac Surgery patIents cOhort
evaluatioN (VISION) Study of 14,687 patients undergoing
non-cardiac surgery showed that withholding ACEIs and
ARBs before surgery was associated with a lower risk of
death and postoperative vascular events.17 The practice of
withholding ACEIs and ARBs preoperatively varies.12 The
concern with continuing these drugs is that intraoperative
hypotension may result in organ hypoperfusion and acute
organ injury. The recent POQI Group consensus recom-
mends withholding ACEIs and ARBs 24 h before surgery.3 If
ACEIs and ARBs are omitted before surgery, then they
should be restarted as soon as appropriate after the oper-
ation, as observational data suggested that failure to do so
was associated with adverse postoperative outcomes.3 In
cardiac surgery, withholding ACEIs and ARBs preopera-
tively is reported to be associated with increased
mortality.3

430 BJA Education - Volume 21, Number 11, 2021


The American College of Cardiology and American Heart
Association recommend that ACEI drugs and ARBs should be
continued perioperatively, based on evidence in the non-
surgical setting that inappropriate discontinuation is associ-
ated with worse outcomes.18 The 2014 European Society of
Cardiology and European Society of Anaesthesiology guide-
lines on non-cardiac surgery also warn about the association
between ACEIs and ARBs and intraoperative hypotension.
However, they suggest continuing ACEIs and ARBs through
the perioperative period in patients who have left ventricular
dysfunction.19
Beta blockers are no longer first-line treatment for high
blood pressure, but are prescribed for a number of condi-
tions. Pre-existing beta-blocker treatment should generally
be continued perioperatively.3 Fixed-dose beta blockade
initiated de novo in the immediate perioperative period may
be associated with an increased risk of perioperative
death.3,20
There is limited evidence available on the perioperative
management of calcium channel blockers and diuretics. The
POQI Group recommends that decisions regarding these drugs
are made on an individual patient basis.3
Ultimately, in the absence of RCTs, and with conflicting
views (particularly with regard to the management of ACEIs
and ARBs), decisions on withholding antihypertensive ther-
apy preoperatively should be made on a case-by-case basis
and care taken to address episodes of hypotension that will
arise if medications are continued. Expert opinion, such as
that from the Perioperative Outcomes Quality Initiative, can
help inform these decisions (Fig. 3).
In most circumstances, it would be unlikely that patients
would be cancelled for surgery if they had accidently taken
their ACEIs on the morning of their procedure. Whilst this
could potentially cause greater degrees of hypotension, this
can be anticipated and management planned accordingly.
Intraoperative management of blood
pressure
General anaesthetic agents can cause hypotension by causing
vasodilation and by reducing cardiac output. Patients with
hypertension can display greater cardiovascular lability dur-
ing surgery with increases in blood pressure and heart rate at
induction of anaesthesia and risks of hypotension in the
intraoperative period.
An observational study of 33,000 patients demonstrated
that an increasing intraoperative duration of a MAP
<55 mmHg was associated with myocardial and acute kidney
injury.21 A recent RCT looked at the effects of individualised
vs standard blood pressure management strategies on post-
operative organ dysfunction in patients undergoing major
surgery.22 Patients in the standard arm received ephedrine
for reductions in systolic blood pressure <80 mmHg or <40%
of the patient’s baseline. Patients in the treatment arm had
their blood pressure maintained within 10% of baseline with
a dilute infusion of noradrenaline (norepinephrine). Patients
in the treatment arm, who had stricter control of their blood
pressure, had significantly lower rates of postoperative organ
dysfunction.22
An adequate blood pressure is required to perfuse cells.
However, this does not always guarantee adequate oxygena-
tion to allow cellular respiration in all tissues.23 For example,
young patients can compensate for the physiological
Preoperative hypertension
challenge of significant hypovolaemia and have normal blood
pressure at the expense of areas of their body being hypo-
perfused. There are multiple factors that affect the perfusion
pressure, including myogenic, neurogenic and metabolic
components. Thus, blood pressure values must be interpreted
in the context of the clinical situation.20
Autoregulation in the circulation of individual organs may
be altered in patients with hypertension, although this is not a
consistent finding across studies.7
Recent publications emphasise the importance of avoiding
intraoperative hypotension, but there is no universal
consensus on thresholds to guide blood pressure
management.3,19,24,25 Maintaining a systolic arterial pressure
of over 100 mmHg and a MAP over 60 mmHg may reduce
risk.3,24 Preoperative blood pressure may be used to guide
intraoperative blood pressure management, with some opin-
ions recommending that blood pressure should be kept within
10% of baseline, or within 20% of baseline in patients with
higher baseline blood pressures (>130/80 mmHg).19,25
Postoperative hypertension
Postoperative hypertension can occur in up to 20% of patients
after elective non-cardiac surgery and is associated with
adverse outcomes, including stroke, myocardial injury, ar-
rhythmias and bleeding.23 There is limited evidence for a
threshold pressure above which harm occurs. However, sys-
tolic pressures over 180 mmHg as indicating high risk, have
been included in a number of validated early warning
systems.23
Conclusions
Perioperative risk stratification for patients with hypertension
is multifactorial and involves patient, anaesthetic and surgi-
cal factors. Changes in community guidelines and the
demonstration of an association between preoperative hy-
potension and increased mortality have implications for
perioperative care and risk stratification. Recent community
hypertension guidelines have introduced more aggressive
treatment targets, meaning more patients will be on antihy-
pertensive medication, some of which may be ‘single pill’
combination therapy. Current practice is informed by obser-
vational studies and expert opinion. Guidance exists to help in
decision making, but ultimately decisions should be made on
a case-by-case basis. Elevated blood pressure in isolation is
not a reason to cancel elective surgery per se with the current
consensus being that it is not possible to set a ‘one size fits all’
threshold above which elective surgery should be deferred.
We must consider each patient’s overall cardiac risk and
make decisions based on this rather than acting solely on
isolated blood pressure readings.
Declaration of interests
SJH is a director and editorial board member of the British
Journal of Anaesthesia. AT declares no conflicts of interest.
MCQs
The associated MCQs (to support CME/CPD activity) will be
accessible at www.bjaed.org/cme/home by subscribers to BJA
Education.
BJA Education - Volume 21, Number 11, 2021 431
Preoperative hypertension
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