What are the guidelines for managing blood pressure after a cardiac catheterization (cardiac cath) procedure?

Blood Pressure Management After Cardiac Catheterization

After cardiac catheterization, blood pressure should be maintained with a systolic blood pressure >90 mmHg or mean arterial pressure ≥60-65 mmHg to reduce the risk of cardiovascular, cerebrovascular, and renal events, as well as mortality. 1

Target Blood Pressure Parameters

• Patient-specific postoperative blood pressure target ranges should be created based on baseline preoperative blood pressure measurements and clinical context 1
• For patients with normal baseline blood pressure, maintain systolic pressure >90 mmHg and <160 mmHg 1
• For mean arterial pressure (MAP), maintain ≥60-65 mmHg 1
• For patients with abnormal baseline values (e.g., systolic >140 or <100 mmHg), targets should be adapted; observational data suggest maintaining intraoperative systolic pressures >70% of preoperative baseline 1

Monitoring Recommendations

• The frequency of postoperative blood pressure surveillance should be determined by patient status and clinical context 1
• Increased frequency of monitoring is recommended for patients with:
  • Decreasing or increasing trends in blood pressure 1
  • Those requiring tighter blood pressure control 1
  • High-risk cardiac patients 1
• Consider continuous blood pressure monitoring when possible, as it can help reduce the severity and duration of hypotension compared to intermittent monitoring 1

Hypotension Management

• Hypotension (MAP <60-65 mmHg or SBP <90 mmHg) in the post-cardiac catheterization period should be promptly treated 1
• Prolonged hypotension is associated with increased risk of myocardial injury, acute kidney injury, and mortality 1
• In the POISE-2 substudy, increasing duration of SBP <90 mmHg through postoperative day 4 was associated with increased risk of MI and death (OR 2.83 per 10-minute increase) 1
• Treatment should be based on the presumed underlying cause 1:
  • Vasodilation: vasopressors
  • Hypovolemia: fluid boluses
  • Bradycardia: chronotropic agents
  • Low cardiac output: inotropic support

Hypertension Management

• Postoperative hypertension can occur due to pain, inflammation, anxiety, hypoxia, volume overload, urinary retention, or withdrawal of chronic antihypertensive medications 1
• Hypertension increases risk for myocardial ischemia/infarction, heart failure, cerebral ischemia, and dysrhythmias 1
• Suggested trigger values for assessment and intervention are systolic pressure >160 mmHg (or >140% of baseline, whichever is lower) 1
• When treating intraoperative hypertension, do so carefully to avoid subsequent hypotension 1

Medication Management

• Chronically taken oral antihypertensive medications should be restarted as soon as clinically reasonable to avoid complications from postoperative hypertension 1
• Delaying resumption of preoperative ACE inhibitors/ARBs has been associated with increased 30-day mortality risk 1
• Caution is advised when continuing antihypertensive therapy in:
  • Patients with low or low-normal perioperative blood pressures 1
  • Older adults (≥65 years) 1
  • Patients at high risk for perioperative hypotension based on clinical status, surgery type, and anesthetic plan 1

Special Considerations

• For patients with coronary artery disease, caution is advised with diastolic blood pressure below 60 mmHg, as coronary perfusion occurs predominantly during diastole 2
• The worst scenario is high systolic blood pressure with low diastolic blood pressure (increased aortic stiffness), but lowering systolic blood pressure is still beneficial even if it further lowers diastolic pressure 2
• For high-risk patients, closer monitoring in an intensive care setting may allow for earlier recognition and treatment of hypotension 1

Level of Care Decisions

• If a patient maintains stable blood pressure within target ranges, they can be transferred from PACU or ICU/HDU to the ward 1
• If a patient has persistent hypotension or hypertension despite appropriate initial therapies, consider transfer to a higher level of care 1