Proceed with Surgery and Optimize Blood Pressure Perioperatively
This patient's blood pressure of 160/95 mmHg is below the critical threshold of 180/110 mmHg, so elective surgery should proceed without postponement, but the GP should be informed to optimize her antihypertensive regimen. 1
Blood Pressure Assessment Algorithm
The most recent 2024 AHA/ACC guidelines and the 2016 British/Irish joint guidelines provide clear thresholds for surgical decision-making:
- BP <160/100 mmHg: Proceed with surgery 1
- BP 160-179/100-109 mmHg: Proceed with surgery but inform GP for optimization 1
- BP ≥180/110 mmHg: Defer surgery and refer back to primary care for blood pressure control 1, 2
This patient's BP of 160/95 mmHg falls into the middle category—proceed with surgery while initiating medication optimization. 1
Rationale for Proceeding
The evidence does not support routine postponement for stage 1-2 hypertension without target organ damage. 1 Multiple studies have failed to demonstrate that delaying surgery to optimize blood pressure in this range reduces perioperative cardiovascular events. 1 The 2024 AHA/ACC guidelines only recommend considering deferral (Class 2b recommendation) for patients with BP ≥180/110 mmHg who have additional cardiovascular risk factors and are undergoing elevated-risk surgery. 1
Diabetes Management Considerations
Her glucose of 9.1 mmol/L (164 mg/dL) is acceptable for proceeding with surgery:
- Target postoperative glucose <180 mg/dL (10 mmol/L) to reduce infection risk 2
- Continue basal insulin at reduced dose perioperatively 2
- Hold SGLT-2 inhibitors the day before and day of surgery due to euglycemic ketoacidosis risk 2
- Continue GLP-1 receptor agonists if applicable, with aspiration risk mitigation 2
Perioperative Medication Management
Continue most antihypertensive medications throughout the perioperative period (Class 2a recommendation): 1, 2
- Beta-blockers: Must continue to avoid rebound hypertension, MI, and arrhythmias 2
- Calcium channel blockers: Continue throughout perioperative period 3
- Clonidine: Continue to avoid harmful rebound hypertension 2
- ACE inhibitors/ARBs: Consider holding on day of surgery due to intraoperative hypotension risk, but restart as soon as clinically feasible postoperatively 1, 2
Intraoperative Blood Pressure Targets
Maintain MAP ≥60-65 mmHg or SBP ≥90 mmHg to reduce myocardial injury risk (Class I recommendation). 1 In this elderly patient with chronic hypertension, consider higher targets to maintain adequate organ perfusion. 1
Postoperative Management
Restart antihypertensive medications as soon as clinically reasonable (Class I recommendation) to avoid complications from postoperative hypertension. 1, 4 Delaying resumption has been associated with increased 30-day mortality. 4
If unable to take oral medications, use IV agents as bridge therapy:
- Nicardipine: First-line for postoperative hypertension 4, 3
- Labetalol: Alternative first-line option 4
Critical Pitfalls to Avoid
- Do not postpone surgery for one month—this is unnecessary and unsupported by evidence for BP <180/110 mmHg 1
- Avoid abrupt discontinuation of beta-blockers or clonidine—this can cause life-threatening rebound hypertension 2
- Do not over-aggressively lower BP postoperatively—target approximately 10% above baseline to avoid hypotension-related complications 4
- In elderly patients (≥65 years), exercise caution with antihypertensive intensification—overly aggressive treatment increases risk of hypotension and associated morbidity 1, 4
Optimal Answer: B - Adjust Medications
The correct answer is B: Adjust her HTN and DM medications. However, this should occur concurrently with proceeding to surgery, not as a reason for postponement. Inform her primary care physician to optimize her antihypertensive regimen for long-term control, ensure her diabetes medications are appropriately managed perioperatively, and proceed with the planned elective surgery. 1, 2