What are the NSQIP (National Surgical Quality Improvement Program) guidelines for managing hypertension in patients undergoing surgery?

NSQIP Guidelines for Perioperative Hypertension Management

In patients undergoing noncardiac surgery, antihypertensive medications should be continued throughout the perioperative period, with specific attention to maintaining intraoperative mean arterial pressure ≥60-65 mmHg or systolic blood pressure ≥90 mmHg to reduce the risk of cardiovascular complications. 1

Preoperative Management

Continuation of Antihypertensive Medications

• Beta blockers: Must be continued if patient has been on them chronically 1

  • Abrupt discontinuation can cause rebound hypertension and is potentially harmful 1, 2
  • Strong recommendation (Class I, Level B-NR)

• Other antihypertensive medications: Generally should be continued until the day of surgery 1

  • Exception: ACE inhibitors/ARBs may be discontinued perioperatively (Class IIb, Level B-NR) 1
  • Rationale: ACE inhibitors/ARBs may increase risk of intraoperative hypotension 1, 2

Blood Pressure Thresholds for Surgery

• Severe hypertension (SBP ≥180 mmHg or DBP ≥110 mmHg):

  • Consider deferring elective surgery, especially in patients with cardiovascular risk factors 1
  • Class IIb recommendation with limited data (Level C-LD)

• Do NOT start beta blockers on the day of surgery in beta blocker-naïve patients (Class III: Harm, Level B-NR) 1

Intraoperative Management

Blood Pressure Targets

• Maintain MAP ≥60-65 mmHg or SBP ≥90 mmHg during surgery 1
  • Strong recommendation (Class I, Level B-NR)
  • Critical for reducing risk of myocardial injury, acute kidney injury, and mortality

Medication Management

• For intraoperative hypertension: Use IV medications until oral medications can be resumed 1
  • Preferred agents based on clinical scenario:
    • Clevidipine, nicardipine: First-line for most perioperative hypertension 1, 2
    • Esmolol, labetalol: Useful when heart rate control is also needed
    • Nitroglycerin: Preferred for acute coronary syndromes 1
    • Fenoldopam: Consider in acute renal failure 1

Postoperative Management

Blood Pressure Control

• Treat postoperative hypotension (MAP <60-65 or SBP <90 mm Hg) promptly 1

  • Strong recommendation (Class I, Level B-NR)
  • Critical to limit cardiovascular, cerebrovascular, and renal events

• Resume preoperative antihypertensive medications as soon as clinically reasonable 1, 2

  • Strong recommendation (Class I, Level C-EO)
  • Delayed resumption associated with increased 30-day mortality

Postoperative Hypertension Management

• Target: Initial 10% reduction from current BP with goal of SBP <160 mmHg and DBP <100 mmHg 2
• First-line oral therapy: Calcium channel blockers (e.g., amlodipine 5-10mg) 2
• Second-line: Beta-blockers (e.g., metoprolol 25-50mg) for tachycardic patients 2
• Reassess: 30-60 minutes after medication administration 2

Common Pitfalls to Avoid

1. Abrupt discontinuation of beta-blockers or clonidine can cause dangerous rebound hypertension 1, 2

2. Starting beta blockers on the day of surgery increases mortality risk in beta blocker-naïve patients 1

3. Ignoring reversible causes of postoperative hypertension:

   • Pain, anxiety, urinary retention, hypoxemia, hypothermia, volume overload 2
   • Address these before administering additional antihypertensives

4. Excessive BP lowering in the perioperative period can lead to organ hypoperfusion

   • Maintain MAP ≥60-65 mmHg or SBP ≥90 mmHg 1

5. Delayed resumption of chronic antihypertensive medications increases 30-day mortality 1, 2

Special Considerations

• Older adults (≥65 years): May require higher BP targets and more cautious medication adjustment 1, 2

• Patients with chronic hypertension: May have altered autoregulation and require higher BP targets 1

• Patients with pacemakers: Calcium channel blockers preferred as first-line; monitor heart rate closely if using beta-blockers 2