How to manage a patient with uncontrolled hypertension undergoing surgery, in terms of American Society of Anesthesiologists (ASA) classification and preoperative treatment?

From the Guidelines

The patient's ASA classification should be ASA 2, as the blood pressure is 150/90, which is not severely elevated. According to the study 1, in patients with hypertension undergoing planned elective major surgery, it is reasonable to continue medical therapy for hypertension until surgery. However, since the patient is not taking any medication, this is not applicable. The study 1 suggests that BP levels of 180/110 mm Hg or greater should be controlled prior to surgery, but the patient's blood pressure is below this threshold. The study 1 recommends that in patients with planned elective major surgery and SBP of 180 mm Hg or higher or DBP of 110 mm Hg or higher, deferring surgery may be considered, but again, the patient's blood pressure does not meet this criteria. Some key points to consider in managing this patient include:

• The patient's blood pressure is not severely elevated, so surgery can proceed without delaying for blood pressure control.
• The patient is not taking any antihypertensive medications, so there is no need to consider continuing or discontinuing medications.
• Intraoperatively, maintaining mean arterial pressure within 20% of baseline can help prevent end-organ hypoperfusion.
• Abrupt withdrawal of antihypertensives is not a concern in this case, as the patient is not taking any medications. The goal is to balance hypertension management with maintaining adequate perfusion during the perioperative period, and in this case, the patient's ASA classification of 2 reflects the relatively low risk associated with their blood pressure 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

ASA Classification

• The American Society of Anesthesiologists (ASA) classification is a system used to evaluate a patient's physical status before surgery.
• For a male patient with uncontrolled hypertension (blood pressure 150/90 mmHg) who is not taking medication, the ASA classification would be ASA 3, as the patient has a severe systemic disease that limits activity but is not incapacitating 2, 3, 4.

Preoperative Treatment

• The patient's uncontrolled hypertension should be managed before surgery to reduce the risk of cardiovascular complications.
• According to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), the patient should receive first-line therapy with thiazide diuretics, and additional antihypertensive therapies should be selected based on the presence of concomitant cardiovascular and metabolic conditions as well as patient-specific factors such as race 2.
• Combination antihypertensive therapy may be necessary to achieve adequate blood pressure control, and the selection of additional antihypertensive agents should be based on the patient's individual needs and medical history 3, 4, 5, 6.

Blood Pressure Management

• The goal of preoperative blood pressure management is to reduce the risk of cardiovascular complications during surgery.
• A target blood pressure of less than 140/90 mmHg is recommended, and the patient's blood pressure should be monitored closely before and during surgery 2, 3, 4, 5, 6.
• The patient's ASA classification and preoperative treatment plan should be individualized based on their specific medical needs and history.