Should All Antihypertensive Agents Be Continued Before Surgery?

INTRODUCTION

Hypertension affects approximately 45% of the United States (U.S.) population and is a leading cause of mortality both nationally and globally. In light of the high prevalence of hypertensive heart disease, the American College of Cardiology and American Heart Association (ACC/AHA) updated prior guidelines for the prevention, detection, and treatment of high blood pressure in adults. These guidelines define blood pressure as either normal, elevated, or Stage 1 or 2 hypertension based on systolic and diastolic pressure criteria. These new thresholds mark a change from previous definitions of hypertension by including in the current Stage 2 category those patients who were previously classified as either Stage 1 or 2. Furthermore, the updated guidelines have recommended pharmacologic antihypertensive therapy at lower systolic and diastolic blood pressure values. Given the high prevalence of hypertension and the drive to institute earlier management, it is not surprising that antihypertensives rank among the most commonly prescribed medications ( Box 12.1 ) and so are commonly encountered in the perioperative period.

OPTIONS

Hypertensive patients undergoing surgery may or may not require adjustment of their antihypertensive regimen to optimize their perioperative management. This decision as to whether to continue or hold an antihypertensive preoperatively depends on a comprehensive risk–benefit analysis ( Box 12.2 ). The possible risks from continuation or discontinuation of an ambulatory antihypertensive medication may be categorized as follows:

• 1.

  The risk for inadequate control of hypertension with possible increased perioperative cardiovascular risk if a particular agent is discontinued before surgery

• 2.

  The risk for a clinically significant withdrawal syndrome and increased perioperative cardiovascular risk if a particular agent is discontinued before surgery

• 3.

  The risk for an adverse perioperative cardiovascular event, such as hypotension, if a particular agent is continued until the day of surgery

EVIDENCE