What are the NSQIP (National Surgical Quality Improvement Program) guidelines for preoperative clearance in patients with hypertension?

NSQIP Guidelines for Preoperative Clearance in Hypertensive Patients

Elective surgery should be deferred in patients with severe hypertension (SBP ≥180 mmHg or DBP ≥110 mmHg) until blood pressure is adequately controlled. 1, 2

Blood Pressure Thresholds for Surgery

• Proceed with surgery: BP <160/100 mmHg
• Consider postponing: BP 160-179/100-109 mmHg (especially with target organ damage)
• Defer surgery: BP ≥180/110 mmHg 1, 2

Preoperative Medication Management

Beta Blockers

• Continue beta blockers in patients already taking them chronically 1, 2
• Do not start beta blockers on the day of surgery in beta blocker-naïve patients 1, 2
• Avoid abrupt discontinuation of beta blockers or clonidine as this can cause rebound hypertension 1

ACE Inhibitors/ARBs

• May be discontinued 24 hours before surgery to reduce risk of intraoperative hypotension 1, 2
• Recent evidence suggests patients who stopped ACE inhibitors/ARBs 24 hours before noncardiac surgery had fewer adverse outcomes 1

Other Antihypertensives

• Generally continue until the day of surgery 2
• For patients unable to take oral medications, use appropriate intravenous alternatives 1

Intraoperative Management

• Maintain mean arterial pressure ≥60-65 mmHg or systolic blood pressure ≥90 mmHg 2
• Patients with intraoperative hypertension should be managed with intravenous medications until oral medications can be resumed 1

Postoperative Management

• Resume preoperative antihypertensive medications as soon as clinically feasible 2
• Delayed resumption is associated with increased 30-day mortality 2
• Treat postoperative hypertension to reduce risk of complications (myocardial ischemia, arrhythmia, stroke) 2

Special Considerations

Elderly Patients (≥65 years)

• May require higher BP targets and more cautious medication adjustment 2
• Patients with chronic hypertension may have altered autoregulation 2

Assessment of Reversible Causes

• Before administering antihypertensive medication, assess for reversible causes such as:
  • Pain
  • Anxiety
  • Urinary retention
  • Hypoxemia
  • Hypothermia
  • Volume overload
  • Medication withdrawal 2

Common Pitfalls to Avoid

1. Starting beta blockers on the day of surgery - increases mortality risk 1, 2
2. Abrupt discontinuation of chronic antihypertensive medications - can cause rebound hypertension 1
3. Aggressive treatment of mild to moderate hypertension immediately before surgery - may lead to intraoperative hypotension 2
4. Delaying surgery unnecessarily for BP <180/110 mmHg without other risk factors - increases risks from delayed treatment 2
5. Failing to assess for target organ damage in patients with hypertension - this affects perioperative risk more than BP alone 3

Treatment Algorithm for Postoperative Hypertension

1. First-line: Calcium channel blockers (e.g., amlodipine 5-10mg PO)
2. Second-line: Beta-blockers (e.g., metoprolol 25-50mg PO) in tachycardic patients
3. Avoid ACE inhibitors/ARBs in the immediate post-op period in volume-depleted patients 2

By following these evidence-based guidelines, perioperative management of hypertensive patients can be optimized to reduce cardiovascular risk and improve surgical outcomes.