HYPERTENSION:

Normal blood pressure has been defined as systolic blood pressure (BP) < 120 mm Hg and diastolic
blood pressure <80 mm Hg by seventh Joint National Committee (JNC). It is estimated that after a
blood pressure of 115/75 mm Hg, every increase of systolic BP by 20 mm Hg or diastolic BP of 10 mm
Hg raises the risk of cardiovascular disease. JNC-7 has divided hypertension into following
subgroups:

Raised blood pressure is one of the most frequent abnormality encountered during pre-anaesthetic
assessment of surgical patients. In India, these patients fall into one of the following categories:

1. Known hypertensive patients, on regular treatment, with or without controlled BP.

2. Known hypertensive patients, with poor compliance of medical treatment, and have poor
control of blood pressure.
3. Patients whose blood pressure has never been checked before but have raised blood
pressure on preoperative evaluation.

Diagnosis and management of hypertension is important in perioperative period as it is a risk factor

for cardiovascular disease. Impact of hypertension on vital end-organs (left ventricular hypertrophy,
coronary artery disease, heart failure, chronic kidney disease, peripheral arterial disease and
retinopathy) must be evaluated. In addition, raised blood pressure can be a manifestation secondary
to other more serious condition like pheochromocytoma, obstructive sleep apnoea, coarctation of
aorta, Cushing’s syndrome, primary hyperaldosteronism, renal artery stenosis, thyroid disease and
chronic kidney disease. Secondary hypertension is found in higher percentage of young patients and
must be identified. Some antihypertensive medications have significant cardiovascular and
metabolic effects and require evaluation before anaesthesia. If inadequate control of BP control is
found, these medications need modification.

Secondary Hypertension:

Secondary hypertension is much more common in younger patients with hypertension. Following
features and investigations may aid. diagnosis of secondary hypertension:

1. Pheochromocytoma: episodic palpitation, sweating, headache (pounding type) and postural

hypotension. Investigations: metanephrines in urine and plasma, MRI, MIBG
(Metaiodobenzylguanidine) scan.
2. Obstructive sleep apnoea: snoring, daytime sleepiness, tiredness, male, obesity, neck
circumference>40 cm and age>50 years. Investigations: STOP- BANG Questionnaire,
polysomnography, home sleep study.
3. Coarctation of the aorta: children and young adult, raised BP in upper limbs,
delayed/diminished femoral pulse. Investigation: echocardiography, CT angiography.
4. Primary aldosteronism (Conn Syndrome): Hypokalaemia, polyuria, nocturia, muscle
weakness, family history. Investigation: increased aldosterone, reduced renin, CT, MRI.
 5. Renovascular hypertension: recurrent pulmonary oedema, deranged renal function,
abdominal bruit, smoking, young age. Investigation: ultrasound, CT angiography or magnetic
resonance angiography.

Several drugs including oral contraceptives, NSAIDs, steroids, buspirone, fluoxetine and tricyclic
antidepressants also cause elevated blood pressure. All causes of secondary hypertension must
be identified and treated, if possible.

Target organ damage:

Hypertension is a risk factor for cardiovascular disease and is implicated in coronary artery
disease, heart failure, left ventricular hypertrophy, atrial fibrillation, aortic aneurysm,
peripheral artery disease, cerebrovascular disease, renal insufficiency, retinopathy. Relevant
history and physical examination for assessment of the above conditions is important.
Following evidence indicate end organ damage:
1. Coronary artery disease: retrosternal chest discomfort/heaviness/pressure/pain may be
radiating to left arm, neck, jaw, inter-scapsular area or epigastrium-provoked by exertion
and relieved by rest/nitrites, exertional dyspnoea, anginal equivalents (non-cardiac chest
pain, diaphoresis, dyspnea, fatigue), ECG:Q wave, ST-T changes.
2. Heart failure: exertional dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, edema,
distended neck veins, rales, third heart sound, hepato-jugular reflex, cardiomegaly.
3. Left ventricular hypertrophy: dyspnea, fatigue, ECG: Sokolow-Lyon index: S in V1 + R in V5 or
V6 (whichever is larger) ≥ 35 mm OR R in aVL ≥ 11 mm, echocardiography
4. Atrial fibrillation: irregularly irregular pulse, palpitation, stroke.
5. Cerebro-vascular disease: acute unilateral weakness, dysphasia, unconsciousness.
6. Renal insufficiency: decreased urine output, abnormal renal function tests.
7. Peripheral artery disease: intermittent claudication.

Management of Hypertension:

Lifestyle modifications are recommended for all patients with prehypertension and above. These
include:

1. Weight reduction to BMI between 18.5 to 24.9 kg/m2

2. Reduced dietary sodium intake to less than 2.4g/day
3. Regular exercise for at least 30 minutes per day
4. Healthy diet rich in fruits, vegetables, and low fat.
5. Limit alcohol consumption to ≤ 2 drinks per day for males and ≤1 drink per day for
females.

Patient population Treatment threshold Target BP Initial/Preferred drug

≥60 year SBP≥150, DBP≥90 SBP<150, DBP<90 Thiazide, CCB, ACEI
<60 year SBP≥140, DBP≥90 SBP<140, DBP<90 or ARB
≥18 year with DM SBP≥140, DBP≥90 SBP<140, DBP<90
≥18 year with CKD SBP≥140, DBP≥90 SBP<140, DBP<90 ACEI, ARB

Antihypertensive medications are recommended as per following table. For compelling

indications (specific coexisting disease in which particular antihypertensive is more
beneficial), the preferred drugs are also indicated. All patients requiring antihypertensive
pharmacotherapy should also continue to have healthy lifestyle lifelong.

SPECIFIC DRUGS & CLASSES:

1. Thiazide- type Diuretics: These inhibit reabsorption of sodium and chloride in renal
tubules and inhibit active excretion of potassium. They also cause vasodilation.
Commonly used agents are hydrochlorthiazide, chlorthalidone and indapamide.
Thiazide-type diuretics are among the first-line medications for management of
hypertension. Side-effects include: volume depletion, hyponatraemia, hypokalaemia,
hypomagnesaemia, hyperuricemia, gout, increased cholestrol and precipitation of
diabetes mellitus.
2. Loop diuretics: These block the Sodium-Potassium-Chloride co-transporter in the
ascending loop of HenIe- causing loss of sodium, potassium, chloride & hydrogen ions in
urine. Their site of action is different from thiazide-like diuretics and hence they have
additive effect and are used mostly in combination with them. In contrast to thiazide
type diuretics, these are high-ceiling diuretics. Furosemide is shorter acting and has
inconsistant oral absorption compared to torsemide.
3. Potassium-sparing diuretics/Aldosterone antagonists: Relatively weak diuretics,
generally used in conjugation with other diuretics to reduce the risk of hypokalaemia.
Spironolactone, amiloride and trimterene are especially useful in patients of
hypertension with hypokalaemia, ascites, edema and Conn Syndrome. Side effects
include: hyperkalaemia, acidosis, gyanecomastia, erectile dysfunction and menstrual
irregularaties.
4. Calcium channel blockers (CCB): Block L-type ( long lasting ) voltage sensitive calcium
channels. Two distinct groups of CCB are in clinical use. Dihydropyridine group consists
of amlodipine, nifedipine, nimodipine and nicardipine. These cause vascular smooth
muscle relaxation and vasodilation. These do not cause myocardial depression and may
cause reflex tachycardia. Non-dihydropyridine group includes verapamil and diltiazem.
These directly depress SA node rate, AV node conduction velocity, and myocardial
contractility. Dihydropyridine CCB are used as first-line antihypertensive. Side-effects
include lower limb edema, tachycardia, flushing and headache.
5. Angiotensin-converting Enzyme Inhibitors (ACEI): These block ACE, which converts
angiotensin I to angiotensin II. Angiotensin II causes systemic vasoconstriction and
retention of sodium and water leading to hypertension. Captopril, enalapril, ramipril and
lisinopril are some of the commonly used ACEI as first-line treatment of hypertension.
These are helpful in management of patients with heart failure, post-myocardial
infarction, reno-vascular hypertension, proteinuria and coexisting diabetes mellitus.
 Class-specific side effects are cough, angioedema, hyperkalaemia, hypotension and feto-
toxicity.
6. Angiotensin II-receptor Blockers (ARB): These include losartan, telmisartan, valsartan,
and olmesartan and are used as alternatives to ACEI. Unlike ACEI, these do not raise the
level of bradykinin and hence do not cause cough and angioedema.
7. Beta-Blockers (BB): Various mechanisms by which BBs reduce blood pressure include
reduction in cardiac output, reducing pressor response to catecholemines, inhibiting
nor-adrenaline and renin release. Propranolol and sotaloI block both beta-1 and beta -2
receptors (non-selective BB/ first-generation) and hence may cause bronchospasm in
patients with reactive airway disease. Second-generation/Cardio-selective BB (only Beta-
I effect) like metoprolol, atenolol, esmolol, acebutolol and betaxlol are relatively safer in
these patients and do not induce bronchospasm, especially at lower doses. Third-
generation BB (labetalol, carvedilol) have additional alpha-adrenergic receptor blocking
property, causing vasodilation. Pindolol has intrinsic sympathomimetic activity and is
useful in patients with bradycardia. BB are not considered to be first-line drugs for
management of hypertension. These are useful in patients with recent myocardial
infarction, systolic heart failure, hypertrophic cardiomyopathy, tachyarrhythmia,
migraine, anxiety and thyrotoxicosis. BB should be avoided in patients with
decompensated heart failure, baseline bradycardia, heart block (second degree or
more). BB interfere with Iipolysis (Beta-3 receptor mediated) and can cause
dyslipidemia. They reduce glucose tolerance and can mark the adrenergic symptoms of
hypoglycemia in diabetic patients. Abruptly discontinuing BB can precipitate withdrawal
symptoms including tachycardia, hypertension anxiety and myocardial infarction.
8. Other agents: Phenoxybenzamine and prazosin are alpha-1 adrenergic receptor
antagonists. Phenoxybenzamine has some alpha-2 adrenoreceptor blocking property
and is a non-competitive inhibitor having long duration of action. Prazosin is shorter
acting, has no alpha-2 blocking property and has non-competitive action; so it is easily
titrable and does not require discontinuation before surgery. All vasodilators cause
postural hypotension.
Nitroglycerin and sodium nitroprusside are nitric oxide donors. Both dilate capacitance
vessels, but sodium nitroprusside acts on arterioles and lowers systemic vascular
resistance.
Hydralazine preferentially dilates arterioles reduces systemic vascular resistance. It is
used as an antihypertensive ill patients with pre-eclampsia.
Alpha-methyldopa gets converted to alpha-methyl noradrenaline in central nervous
system, which acts on central alpha-2 adrenoreceptors and reduces the central
sympathetic outflow.
Clonidine also acts on central alpha-2 adrenoreceptors to reduce blood pressure and
anxiety.

Anaesthetic implications:

All patients should have their BP recorded during pre-anaesthetic evaluation as several patients will
be first diagnosed as hypertensive during the pre-anaesthetic check-up. The risk factors and end-
organ damage due to hypertension should be evaluated and quantified. All hypertensive patients
should be screened for possible secondary causes of hypertension. Undiagnosed
pheochromocytoma can be life threatening during peri-operative period. Adequacy of blood
pressure control should be evaluated. Ambulatory or in-hospital charting of blood pressure can be
helpful in cases of ‘white-coat’ hypertension. Adequacy of blood control is desirable before surgery,
but inadequate blood control does not preclude elective surgery. There is no evidence that delaying
surgery for systolic BP<180 mm Hg or diastolic BP<110 is beneficial. Above this threshold, delaying
the surgery for blood control can be considered. Peri-operative risks associated with poorly
optimized hypertension are: increased blood loss, myocardial ischemia, cerebro-vascular accidents.
Increased risk of hypotension in volume-depleted and altered vascular response in patients with
right-side shifted curve of organ autoregulation raises the risk of end organ hypoperfusion, especially
of kidney and central nervous system. Reviewing the vitals chart of the patient to establish the
baseline blood pressure of the patient can help perioperative management and setting the target
range of blood pressure control.

Medication management:

It is imperative to know the adverse effects of antihypertensive agents and evaluate them in pre-
operative check-up……..

All antihypertensive agents should be continued till the morning of surgery. Withholding
antihypertensive agents prior to surgery can cause raise in blood pressure pre/intra-operatively.
Stopping beta blockers and clonidine before surgery can lead to redound hypertension and
tachycardia. Possible exceptions to this rule include ACEI and ARB in patients scheduled to undergo
surgery with expected large fluid shifts as these agents have potential to cause refractory
hypotension. Morning dose of these agents are withheld before surgeries with large fluid shift.

Beta blockers should not be started in immediate pre-operative period (within 24 hours) as this has
shown to cause increased hemodynamic instability intraoperatively.