What to do with an elderly female patient with hypertension (HTN) and diabetes mellitus (DM) who has elevated blood pressure and glucose level prior to elective surgery?

Adjust HTN and DM Medications - Do Not Postpone Surgery

For this elderly female patient with BP 160/95 mmHg and glucose 9.1 mmol/L (164 mg/dL) before elective surgery, you should adjust her antihypertensive and diabetes medications and proceed with surgery rather than postponing for one month. 1

Rationale for Proceeding with Surgery

Blood Pressure Assessment

• The BP of 160/95 mmHg does not mandate surgical postponement. Joint guidelines from the Association of Anaesthetists and British Hypertension Society indicate that only BP ≥180 mmHg systolic or ≥110 mmHg diastolic warrants considering deferral of elective surgery. 1

• Postponing surgery for BP optimization provides minimal cardiovascular benefit when weighed against surgical delay risks. The lifelong cardiovascular risk reduction from one month of antihypertensive therapy is negligible (approximately 0.2-0.6 events per 1000 patients per month), while each postponed month increases cardiovascular risk by 1% due to patient aging. 1

• The evidence shows that in patients with diastolic BP 110-130 mmHg who received immediate BP treatment and proceeded with surgery versus those who had surgery delayed, there was no difference in neurological or cardiovascular complications during the first three postoperative days. 1

Glycemic Control Assessment

• The glucose of 9.1 mmol/L (164 mg/dL) is acceptable for proceeding with surgery. The American Diabetes Association recommends a perioperative blood glucose target range of 100-180 mg/dL (5.6-10.0 mmol/L) within 4 hours of surgery. 1

• The A1C target for elective surgeries should be <8% (63.9 mmol/mol) whenever possible, but this patient's single glucose reading of 9.1 mmol/L does not indicate prohibitively poor control. 1

Perioperative Management Algorithm

Preoperative Optimization (Day Before/Day of Surgery)

Antihypertensive Management:

• Continue all chronic antihypertensive medications until the morning of surgery, with specific attention to beta blockers and clonidine (abrupt discontinuation is harmful). 1
• If the patient is on ACE inhibitors or ARBs, consider holding these on the day of surgery (though this remains controversial). 1
• The American College of Cardiology recommends continuing calcium channel blockers throughout the perioperative period. 2

Diabetes Management:

• Hold metformin on the day of surgery. 1
• Discontinue SGLT2 inhibitors 3-4 days before surgery. 1
• Give half the NPH insulin dose or 75-80% of long-acting analog insulin on the morning of surgery. 1
• Hold other oral glucose-lowering agents the morning of surgery. 1

Intraoperative Management

Blood Pressure:

• Target intraoperative mean arterial pressure ≥60-65 mmHg or systolic BP ≥90 mmHg to reduce risk of myocardial injury. 2
• For hypertension (BP ≥160/90 mmHg or systolic elevation ≥20% of preoperative value persisting >15 minutes), use IV agents such as nicardipine, labetalol, or clevidipine. 1, 3

Glucose:

• Monitor blood glucose every 2-4 hours while NPO. 1
• Maintain perioperative glucose 100-180 mg/dL (5.6-10.0 mmol/L). 1
• Use short- or rapid-acting insulin for corrections as needed. 1

Postoperative Management

Blood Pressure:

• Resume preoperative antihypertensive medications as soon as clinically feasible (oral intake tolerated). 1, 3
• Target BP approximately 10% above the patient's baseline. 3
• If oral medications cannot be resumed, use IV nicardipine or labetalol as bridge therapy. 3
• Delaying resumption of ACE inhibitors/ARBs has been associated with increased 30-day mortality. 3

Glucose:

• Use basal-bolus insulin regimen (basal insulin plus premeal short/rapid-acting insulin) rather than correction-only sliding scale, as this improves glycemic outcomes and reduces perioperative complications. 1
• Continue monitoring blood glucose regularly until oral intake is established. 1

Critical Pitfalls to Avoid

• Never start beta blockers on the day of surgery in beta blocker-naïve patients - this is associated with harm. 1
• Never abruptly discontinue beta blockers or clonidine preoperatively - this is potentially harmful. 1
• Avoid excessive BP reduction - overly aggressive treatment can cause hypotension, which increases risk of myocardial infarction and death. 3
• Do not use correction-only insulin sliding scales alone without basal insulin coverage, as this approach is inferior to basal-bolus regimens. 1

Why Postponement Is Not Indicated

• One month of delay provides negligible cardiovascular benefit (0.2-0.6 fewer events per 1000 patients) while exposing the patient to aging-related risk increase. 1
• Current BP and glucose levels are manageable within accepted perioperative parameters. 1
• Patients with smoking or hypercholesterolemia are not routinely subjected to surgical cancellations, highlighting the inconsistency of postponing surgery solely for moderate BP elevation. 1