What are the preoperative clearance considerations for a 79-year-old patient undergoing cataract surgery with a history of hypertension, diabetes mellitus, and hyperlipidemia, currently on amlodipine, metoprolol, valsartan, and Paxil (paroxetine), and aspirin, following a recent carotid artery endarterectomy?

From the Guidelines

I recommend proceeding with cataract surgery with appropriate perioperative management, prioritizing the patient's morbidity, mortality, and quality of life as the primary outcome. The patient should continue taking amlodipine, metoprolol, valsartan, and Paxil without interruption through the perioperative period, as recommended by the 2018 ACC/AHA/AAPA/ABC/ACPM/AGS/APHA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1.

Perioperative Management

• The patient should continue their antihypertensive medications, including beta blockers, until the day of surgery, as abrupt discontinuation can be harmful 1.
• Aspirin should be discontinued 7 days before surgery due to the recent carotid endarterectomy and increased bleeding risk, and can be resumed 24 hours after surgery if hemostasis is adequate, considering the guidelines for management of patients with extracranial carotid and vertebral artery disease 1.
• Blood pressure should be well-controlled (ideally <140/90 mmHg) before surgery, and blood glucose should be monitored closely with a target of 140-180 mg/dL on the day of surgery.
• The patient should take their morning antihypertensive medications with a small sip of water on the day of surgery.
• For diabetes management, oral medications should be held the morning of surgery, while insulin doses may need adjustment (typically 50% of long-acting insulin).

Cardiovascular Risk

• Cardiac risk appears acceptable for this low-risk procedure, but the anesthesiologist should be informed of the patient's cardiovascular history, recent carotid surgery, and medication regimen.
• The patient's hypertension, diabetes, and hyperlipidemia increase perioperative risk slightly, but cataract surgery is minimally invasive with low cardiovascular stress, making serious complications unlikely with proper management, as supported by the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery 1.

Recent Carotid Endarterectomy

• The recent carotid endarterectomy increases the risk of bleeding, and therefore, aspirin should be discontinued before surgery, but can be resumed after surgery if hemostasis is adequate, considering the guidelines for management of patients with extracranial carotid and vertebral artery disease 1.

Quality of Life

• The patient's quality of life should be prioritized, and cataract surgery can improve their vision and overall well-being, making it a beneficial procedure with proper perioperative management.

From the Research

Preoperative Clearance for Cataract Surgery

The patient is a 79-year-old with hypertension, diabetes, hyperlipidemia, and a recent carotid artery endarterectomy. They are currently on amlodipine, metoprolol, valsartan, Paxil, and aspirin.

Medication Management

• The patient's current medications, including amlodipine, metoprolol, and valsartan, are commonly used to manage hypertension 2, 3.
• Aspirin is often used in patients with a history of carotid artery endarterectomy to prevent further cardiovascular events.

Hypertension and Cataract Surgery

• Hypertension is a prominent risk factor in patients undergoing cataract surgery, with a significant association between hypertension and the development of cataracts 4.
• The study found that hypertension was the most frequent risk factor, ranging from 43.8% in patients with subcapsular cataracts to 27.6% in patients with mixed type cataracts.

Post-Carotid Endarterectomy Hypertension

• Post-endarterectomy hypertension (PEH) is a well-recognized phenomenon after carotid endarterectomy, associated with post-operative intracranial hemorrhage, hyperperfusion syndrome, and cardiac complications 3, 5.
• The incidence of PEH was found to be 38% in one study, with patients requiring treatment for PEH having a significantly higher pre-operative systolic blood pressure and evidence of pre-existing impairment of baroreceptor sensitivity 3.
• Another study found that eversion carotid endarterectomy (E-CEA) increases the risk for post-CEA hypertension, whereas conventional carotid endarterectomy (C-CEA) is more often associated with hypotension 5.

Cerebral Hyperperfusion Syndrome

• Cerebral hyperperfusion syndrome is a preventable cause of stroke after carotid endarterectomy, manifesting as headache, seizures, hemiparesis, or coma due to raised intracranial pressure or intracerebral hemorrhage (ICH) 6.
• The incidence of severe hypertension was found to be 19%, that of cerebral hyperperfusion 1%, and ICH 0.5% after carotid endarterectomy.
• The postoperative mean systolic blood pressure of patients who developed cerebral hyperperfusion syndrome was 164 mmHg, with a cumulative incidence of cases rising appreciably above a postoperative systolic blood pressure of 150 mmHg 6.