From the Guidelines
The patient should continue her antihypertensive medications, including beta-blockers, through the morning of surgery to minimize the risk of rebound hypertension and perioperative cardiac complications, as recommended by the 2017 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.
Preoperative Management Strategies
To optimize the patient's cardiovascular status and ensure appropriate management of her glaucoma, the following strategies should be considered:
- Continue antihypertensive medications, including beta-blockers, calcium channel blockers, and ACE inhibitors, as sudden discontinuation may lead to rebound hypertension 1.
- Continue statins for hyperlipidemia to provide perioperative cardioprotection.
- Maintain intraocular pressure control with prostaglandin analogs like latanoprost, and consider dose adjustment for oral carbonic anhydrase inhibitors like acetazolamide based on renal function.
- Individualize the decision to continue antiplatelet agents like aspirin based on bleeding risk and cardiovascular risk factors.
Blood Pressure Management
- Optimize blood pressure to <160/90 mmHg before proceeding with surgery to minimize the risk of intraoperative bleeding and postoperative complications 1.
- Consider deferring surgery if the patient's systolic blood pressure is 180 mm Hg or higher or diastolic blood pressure is 110 mm Hg or higher, as recommended by the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline 1.
Additional Considerations
- The patient should fast for 6 hours for solid food and 2 hours for clear liquids before surgery.
- Monitor renal function and serum potassium levels if ACE inhibitors, ARBs, or diuretics are used, as recommended by the American Heart Association and the American Diabetes Association 1.
From the Research
Preoperative Management Strategies
To advise the 73-year-old female patient with hypertension and hyperlipidemia undergoing eye surgery for open-angle glaucoma, consider the following strategies:
- Hypertension management: The patient's hypertension should be controlled before surgery, but the degree of control needed depends on the severity of hypertension and other cardiovascular risk factors 2.
- Medication management: Current evidence supports the perioperative continuation of β-blockers, calcium-channel blockers, and α-2 agonists, while diuretics should be discontinued on the day of surgery and resumed in the postoperative period 3.
- Hyperlipidemia management: For patients with hyperlipidemia, alternative step I antihypertensive agents such as alpha 1-blockers, ACE inhibitors, and calcium channel blockers may be desirable as they do not interfere with lipid therapy or may even improve the lipid profile 4.
- Lipid-lowering therapy: Preoperative statin therapy may be beneficial for hyperlipidemic patients undergoing surgery, as it has been shown to reduce the risk of major adverse cardiac events after coronary artery bypass grafting 5.
- Individualized approach: The patient's age, comorbidities, and concomitant medications should be taken into account when determining the best preoperative management strategy 6.
Key Considerations
- The patient's blood pressure should be well-controlled before surgery, but acute control in the few days before surgery is not necessary for mild to moderate hypertension 2.
- The choice of antihypertensive medication can impact the patient's risk of intraoperative instability and should be carefully considered 3, 2.
- The patient's hyperlipidemia should be managed with a lipid-lowering therapy, such as statins, to reduce the risk of cardiovascular events 5.