Arterial Hypertension in Daily Practice of the Anesthesiologist
This article is based on official guidelines of European Society of Cardiology (ESC) and European Society of Anesthesiology (ESA) on cardiovascular assessment and management in non-cardiac surgery. The presence of arterial hypertension is a risk factor for cardiovascular complications in non-cardiac surgery. Pre-operative evaluation should check and optimize the control of cardiovascular risk factors. According to the systematic review and meta-analysis, pre-operative hypertension was associated with a 35 % increase in cardiovascular complications, but uncontrolled blood pressure is one of the most common causes of delayed operation. When raised blood pressure is discovered for the first time in a pre-operative evaluation, it is advisable to search for target organ damage and evidence of associated cardiovascular pathology (electrocardiography, renal function parameters, and evidence of heart failure), and to initiate therapy to control the blood pressure. During the induction of anaesthesia, sympathetic activation can cause an increase in blood pressure by 20–30 mmHg, and the heart rate increase by 15–20 bpm in normotensive individuals. This response may be more pronounced in patients with untreated hypertension. As the period of anaesthesia progresses, patients with pre-existing hypertension are more likely to experience lability of intra-operative blood pressure, which may lead to myocardial ischaemia. Perioperative instability may include excessive peaks and profound hypotension with baroreflex-mediated tachycardia. Perioperative blood pressure is recommended to be kept at 70–100 % of baseline, avoiding excessive tachycardia. Post-surgical elevation of blood pressure is frequently caused by the anxiety and pain after awakening, and may return to normal after treating these factors. Common reasons for delayed surgery in patients with hypertension are poorly controlled blood pressure of grade 3 according to European Society of Cardiology (systolic blood pressure ≥ 180 mmHg and/or diastolic blood pressure ≥ 110 mmHg), discovery of end-organ damage that has not previously been evaluated or treated, or suspicion of secondary hypertension without properly documented aetiology. In patients with grade 1 or 2 hypertension (systolic blood pressure ˂ 180 mmHg; diastolic blood pressure ˂ 110 mmHg), there is no evidence of benefit from delaying surgery to optimize therapy. In such cases, antihypertensive medications should be continued during the perioperative period. According to ESC/ESA guidelines on peri-operative management of arterial hypertension, we can conclude the following. Most antihypertensive drugs should be continued to the day of surgery and restart as soon as possible (when the patient will be able to swallow). Only agents that affect the renin-angiotensin system should be cancelled — angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. The physical status of patients ≥ 3 according to American Association of Anesthesiologists is a more significant predictor of aggressive hypotension than receiving antihypertensive medication. Systolic blood pressure ˂ 180 mmHg and diastolic ˂ 110 mmHg can’t be considered as a reason of surgery delay. In patients with grade 3 hypertension, the potential benefits of delaying surgery to optimize the pharmacological therapy should be weighed against the risk of delaying the procedure. Perioperative hemodynamic instability (episodes of hypo- and hypertension) is more threatening for the occurrence of cardiovascular complications than isolated blood pressure rise.
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