Does hypertension influence bleeding during surgery?

From the Guidelines

Hypertension does not have a direct, significant influence on bleeding during surgery, according to the most recent and highest quality evidence. The relationship between hypertension and surgical bleeding is complex, and while elevated blood pressure can increase the pressure within blood vessels, the current evidence does not support a significant association between hypertension and increased bleeding risk during surgery 1.

Key Considerations

• The 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery notes that induction of anesthesia can trigger sympathetic activity in patients with untreated or uncontrolled hypertension, resulting in labile BP and heart rate 1.
• However, the guideline also states that in the absence of RCRI components, there is little evidence for increased risk of perioperative complications in patients with preoperative BP of <180/110 mm Hg or at any preinduction BP 1.
• The management of hypertension before elective surgery is focused on balancing the risks of anesthesia, treatment, and delay for the individual patient, rather than solely on reducing blood pressure to prevent bleeding 1.

Implications for Clinical Practice

• Patients with hypertension should inform their surgical team about their condition and all medications they take.
• Good blood pressure control is important for reducing the risk of cardiovascular complications during surgery, but it may not have a significant impact on surgical bleeding.
• The decision to postpone surgery or initiate antihypertensive treatment should be based on individual patient factors, including age, comorbidity, functional capacity, and the urgency and indication for surgery.

Medications and Blood Pressure Control

• Medications commonly used to control blood pressure before surgery include beta-blockers, calcium channel blockers, and ACE inhibitors.
• Some blood pressure medications, particularly ACE inhibitors and angiotensin receptor blockers, may be temporarily discontinued 24-48 hours before surgery based on the surgeon's recommendation.
• During surgery, intravenous medications like labetalol, hydralazine, or nitroglycerin might be used for immediate blood pressure control.

From the Research

Hypertension and Bleeding During Surgery

• Hypertension is a known risk factor for perioperative complications, including cardiovascular events and bleeding 2.
• The relationship between hypertension and bleeding during surgery is complex, and several factors can contribute to bleeding events, including blood pressure lability, medication administration, and patient-related factors such as poorly controlled hypertension 3, 4.

Factors Contributing to Bleeding

• Poorly controlled hypertension is a significant etiology of perioperative hypertension in patients undergoing noncardiac surgeries 2.
• Excessive fluid therapy, excessive vasopressor therapy, and medication withdrawal can also cause perioperative hypertension 2.
• Blood pressure lability, particularly intraoperative blood pressure lability, is associated with postoperative hemorrhage after uncomplicated bariatric surgery 4.
• Changes in systolic blood pressure during hospitalization, particularly elevated blood pressure, are associated with a high risk of bleeding events after percutaneous coronary intervention 3.

Management of Hypertension and Bleeding

• Preoperative control of blood pressure, evaluation of patient risk factors, and continuation of preoperative antihypertensive therapy can help reduce the risk of bleeding during surgery 5.
• Individualized and pathophysiology-based approaches to control blood pressure may be the best option to guide patients through the perioperative period 6.
• Monitoring techniques such as echocardiography and near-infrared spectroscopy can provide crucial information to optimize intraoperative control of blood pressure based on an individual patient's pathophysiology 6.