Can we proceed with elective orthopedic surgery in a patient with hypertension, chronic stroke with residuals, and old inferior septal myocardial infarction (MI), currently on nicardipine (calcium channel blocker) drip with controlled blood pressure?

Proceed with Caution: Surgery Can Continue with Controlled Blood Pressure, But Requires Enhanced Monitoring

In this 71-year-old male with multiple cardiovascular comorbidities and blood pressure controlled to 150/80 mmHg on nicardipine drip, elective orthopedic surgery can proceed, but requires careful perioperative hemodynamic management and close monitoring given his high-risk profile.

Risk Stratification

This patient falls into a high-risk category for perioperative cardiovascular complications based on:

• Age >70 years - independently increases perioperative MI risk (OR 4.77) 1
• History of MI - patients with established CAD have the highest perioperative MI rate (4.1%; OR 10.39) 1
• Prior stroke with residuals - increases risk of recurrent stroke and cardiovascular complications 1
• Orthopedic surgery - while lower risk than vascular surgery, still carries measurable cardiac risk in elderly patients with CAD 1

Blood Pressure Management Decision

Current Blood Pressure Status (150/80 mmHg on nicardipine)

This blood pressure is acceptable to proceed with surgery. The evidence strongly supports:

• Stage 2 hypertension (SBP 150 mmHg) does NOT require surgical delay - multiple guidelines confirm that blood pressure <180/110 mmHg is not an independent risk factor for perioperative cardiovascular complications 1
• The 2024 AHA/ACC guidelines state that deferring surgery "may be considered" only for poorly controlled hypertension (SBP ≥180 or DBP ≥110 mmHg) in patients with cardiovascular risk factors 1
• The 2016 British guidelines explicitly state that blood pressures <180/110 mmHg should not preclude elective surgery 1

Nicardipine Continuation Strategy

Continue nicardipine through the perioperative period:

• Antihypertensive medications should be continued perioperatively to avoid rebound hypertension and reduce cardiovascular complications 1
• Nicardipine is specifically appropriate for perioperative blood pressure control when oral therapy is not feasible 2
• The drug provides effective bridge therapy until oral medications can be resumed postoperatively 3

Perioperative Management Algorithm

Preoperative Phase

1. Maintain nicardipine infusion at current dose achieving 150/80 mmHg 1, 3
2. Target blood pressure approximately 10% above baseline rather than aggressive normalization 3
3. Ensure adequate monitoring capability is available intraoperatively (arterial line strongly recommended given nicardipine drip and cardiac history) 1

Intraoperative Phase

Critical monitoring targets:

• Maintain MAP ≥60-65 mmHg or SBP ≥90 mmHg to reduce risk of myocardial injury 1
• Avoid hypotension - even brief hypotensive episodes may significantly impact outcome, particularly in elderly patients with prior stroke 1, 4
• Expect hemodynamic lability - hypertensive patients demonstrate more pronounced blood pressure fluctuations during anesthesia induction, intubation, and emergence 1

Nicardipine titration:

• Continue infusion at 3-8 mg/hr (typical maintenance range) 2
• Can titrate by 2.5 mg/hr increments up to 15 mg/hr maximum if needed 2
• If hypotension develops, discontinue temporarily and restart at lower dose (3-5 mg/hr) 2

Postoperative Phase

1. Resume oral antihypertensives as soon as clinically feasible - delaying resumption increases 30-day mortality 3
2. Continue nicardipine bridge until oral medications are tolerated 3
3. Treat postoperative hypertension aggressively - affects 25% of major surgery patients and increases risk of cardiovascular events, stroke, and bleeding 1, 3
4. Monitor for hypotension - target MAP ≥60-65 mmHg to limit cardiovascular, cerebrovascular, and renal complications 1

Special Considerations for This Patient

Stroke History Management

• Elective surgery is reasonable ≥3 months after stroke to reduce recurrent stroke risk 1
• Cerebral autoregulation may be impaired - avoid excessive blood pressure reduction that could compromise cerebral perfusion 2, 5
• Nicardipine has cerebrovascular protective properties and is specifically used in stroke management 5, 6

Prior MI Considerations

• This patient has the highest perioperative cardiac risk (4.1% MI rate) 1
• Maintain adequate coronary perfusion pressure - avoid hypotension more aggressively than hypertension 1, 4
• Consider cardiac biomarker monitoring postoperatively given high-risk profile 1

Medication-Specific Cautions

Nicardipine safety profile:

• Does not significantly affect cardiac conduction - safe in patients with conduction abnormalities 7
• May cause reflex tachycardia - monitor heart rate closely 2
• Metabolized hepatically - use caution if liver dysfunction present 2
• Change IV site every 12 hours to minimize venous irritation 2

Critical Pitfalls to Avoid

1. DO NOT delay surgery for blood pressure 150/80 mmHg - no evidence supports benefit, and delay carries its own risks 1

2. DO NOT discontinue nicardipine abruptly - risk of rebound hypertension 1

3. DO NOT aggressively lower blood pressure to "normal" - target 10% above baseline, as excessive reduction increases MI and mortality risk 1, 3

4. DO NOT tolerate intraoperative hypotension - even brief episodes (MAP <60-65 mmHg) increase myocardial injury risk 1

5. DO NOT use small peripheral veins for nicardipine - risk of thrombophlebitis and vascular impairment 2

6. DO NOT delay resuming oral antihypertensives postoperatively - associated with increased 30-day mortality 3

Anesthetic Technique Recommendations

• Consider regional anesthesia if feasible for the orthopedic procedure to reduce systemic hemodynamic stress 1
• Use co-induction techniques to minimize blood pressure swings during induction 1
• Employ depth-of-anesthesia monitoring to avoid excessive anesthetic depth causing hypotension 1
• Have vasopressors immediately available for hypotension management 1