1. Mythbuster: Preoperative Blood Pressure Control
From the Publishers of
Consult Guys
Mythbuster: Preoperative Blood Pressure Control
COPYRIGHT © 2017, ALL RIGHTS RESERVED

2. Terms of Use
The Consult Guys® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of ACP.
The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice.
Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the Consult Guys® slide sets constitutes copyright infringement.
Copyright © 2017

3. A Patient with Hypertension Prior to Surgery
A 65-year-old man presents for elective right total hip replacement.
He has no medical problems and was seen 14 days ago for preadmission testing. At that time his BP 130/80 (his baseline), HR 78.
Physical exam was unremarkable except for limited range of motion of the right hip.
Electrocardiogram was performed and revealed sinus rhythm with LVH.
Vital signs were obtained in the OR holding area and his BP is 170/85. It is unchanged when repeated three times.

4. What is the most appropriate next step?
Cancel surgery and reschedule when BP is at his preop baseline.
Initiate therapy with an ACE inhibitor and follow up in two hours. Proceed to surgery if BP is at baseline.
Initiate therapy with a calcium channel blocker and follow up in two hours. Proceed to surgery if BP is at baseline.
Initiate therapy hydralazine and follow up in one hour. Proceed to surgery if BP is at baseline.
Proceed to surgery.

5. Answer
E. Proceed to surgery

6. Chronic Hypertension
Is chronic hypertension really a risk factor for perioperative complication?
Is elevated BP prior to surgery a problem?
What evidence supports delaying elective surgery in the patient with poorly controlled hypertension?
How much preop BP control is needed and for how long?

7. Chronic Hypertension 34 patients elective anesthesia + surgery
15 “normotensive”
19 hypertensive (treated and untreated)
Mean BP similar in both groups
Untreated had greater decrease in BP at induction
Untreated had more myocardial ischemia
No adverse events in either group
Implication: Defer surgery to treat hypertension

8. Meta analysis of 30 studies
No evidence that preoperative hypertension directly affects periop outcome
Howell SJ, Sear JW, Foëx P. Hypertension, hypertensive heart disease and perioperative cardiac risk. Br J Anaesth. 2004;92: [PMID: ]

9. Stage III BP (>180 / >110) NO Supportive evidence
No perioperative risk
Stage I BP ( / 90-99
Stage II BP ( / )
Control BP preop
Stage III BP (>180 / >110)
NO Supportive evidence
Eagle KA, Berger PB, Calkins H, Chaitman BR, Ewy GA, Fleischmann KE, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery----executive summary a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation. 2002;105: [PMID: ]

10. Preoperative Evaluation Guideline
ACC / AHA 2007
Preoperative Evaluation Guideline
Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. Circulation. 2007;116:e [PMID: ]

11. Preoperative Hypertension Guideline 2016
Hartle A, McCormack T, Carlisle J, Anderson S, Pichel A, Beckett N, 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: [PMID: ] doi: /anae.13348

12. Preoperative Hypertension Guideline 2016
No evidence that preoperative hypertension affects postop outcome
Hypertension is a common reason to cancel surgery
Outpatient BP < 160/100 mm Hg should precede referral for nonurgent elective surgery
When seen in outpatient presurgery clinic if :
BP > 140/80 but BP < 180/110
Inform general practitioner but no indication to cancel surgery
Hartle A, McCormack T, Carlisle J, Anderson S, Pichel A, Beckett N, 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: [PMID: ] doi: /anae.13348

13. Major Issues of Chronic Hypertension
More comorbidities
CAD
CHF
CRF
Too aggressive control of BP a problem
Increased periop hemodynamic lability/hypotension

14. more likely if ACE or ARB taken during prior 10 hours
Retrospective
During first 30 minutes postinduction moderate hypotension (systolic BP < 85 mm Hg)
more likely if ACE or ARB taken during prior 10 hours
No difference in postop complications
Discontinuation of ACE/ARB at least 10 hours preinduction associated with reduced
risk for immediate postinduction hypotension
Comfere T, Sprung J, Kumar MM, Draper M, Wilson DP, Williams BA, et al. Angiotensin system inhibitors in a general surgical population. Anesth Analg. 2005;100:636-44, table of contents. [PMID: ]

15. 2014 ACC/AHA Perioperative Guideline Systematic Review Report Perioperative ACE Inhibitor Management
Continuation of ACE inhibitor or ARB perioperatively is reasonable
If ACE inhibitor or ARB is held before surgery, it is reasonable to restart as soon as clinically feasible postoperatively

16. Withheld ACE-I/ARB 24 hours before surgery
18% less likely to have 30-day all cause death, stroke, MI, myocardial injury
Intraoperative hypotension common (more common when ACEI/ARB continued) but not associated with mortality or MI
ACEI/ARB continued: 28.6% hypotension
ACEI/ARB withheld: 23.3% hypotension
Postoperative hypotension common (same in both groups) and associated with increased risk of death, MI, myocardial injury
ACEI/ARB continued :20.2%
ACEI/ARB withheld: 19.4%
Confusing results
Need a large trial to clarify whether to withhold ACEI/ARB
Roshanov PS, Rochwerg B, Patel A, Salehian O, Duceppe E, Belley-Côté EP, 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: [PMID: ]

17. Systolic BP <50% of baseline Lasting > 5 minutes
Hallqvist L, Mårtensson J, Granath F, Sahlén A, Bell M. Intraoperative hypotension is associated with myocardial damage in noncardiac surgery: An observational study. Eur J Anaesthesiol. 2016;33: [PMID: ] doi: /EJA

18. Myocardial, kidney injury
MAP < 65
Myocardial, kidney injury
Salmasi V, Maheshwari K, Yang D, Mascha EJ, Singh A, Sessler DI, et al. Relationship between Intraoperative Hypotension, Defined by Either Reduction from Baseline or Absolute Thresholds, and Acute Kidney and Myocardial Injury after Noncardiac Surgery: A Retrospective Cohort Analysis. Anesthesiology. 2017;126: [PMID: ]

19. Preoperative Hypertension
First, do no harm!
Hypertension without end-organ damage not a risk
No clear evidence to support urgent BP lowering
Hypotension is the problem

20. Produced by
and
COPYRIGHT © 2017, ALL RIGHTS RESERVED