Management of Hypertension in Patients Undergoing Anesthesia

Classification and Risk Assessment

Hypertension is categorized into stages based on blood pressure readings, with Stage 1 being 140-159 mmHg systolic or 90-99 mmHg diastolic, Stage 2 being 160-179 mmHg systolic or 100-109 mmHg diastolic, Stage 3 being 180-209 mmHg systolic or 110-119 mmHg diastolic, and Stage 4 being ≥210 mmHg systolic or ≥120 mmHg diastolic 1

Hypertensive patients demonstrate more labile hemodynamic profiles during anesthesia compared to normotensive patients, with induction of anesthesia and airway instrumentation triggering pronounced sympathetic activation, leading to significant increases in blood pressure and heart rate 3
Patients with Stage 1 or 2 hypertension without target organ damage do not have clearly established increased perioperative cardiovascular risk, but hypertension with target organ damage is associated with a small increased incidence of perioperative major adverse cardiovascular events 4

Blood pressure should be measured in primary care before non-urgent surgical referral, and blood pressures less than 180 mmHg systolic and 110 mmHg diastolic should not preclude elective surgery, according to the American College of Cardiology 2
For patients with well-controlled hypertension on medication, most antihypertensive medications should be continued perioperatively, but angiotensin-converting enzyme inhibitors and receptor blockers may be omitted on the day of surgery to reduce significant hemodynamic fluctuations 5, 3

Techniques to achieve hemodynamic stability, such as co-induction, invasive arterial monitoring with titrated vasopressor therapy, depth-of-anesthesia monitoring, and stroke volume optimization with appropriate fluid therapy, should be implemented 4, 1, 3

Emergency or urgent surgery must almost always proceed regardless of blood pressure control, and all involved parties should be made aware of any associated increased risk 6
Abrupt withdrawal of antihypertensive medications, particularly beta-blockers, should be avoided as it may precipitate rebound hypertension and myocardial ischemia, according to the American Heart Association 2