What is the best course of action for an elderly female patient with a history of Hypertension (HTN) and Diabetes Mellitus (DM), presenting with uncontrolled blood pressure and elevated glucose levels, who is scheduled for elective surgery?

Adjust Her HTN and DM Medications (Option B)

The best course of action is to proceed with surgery while optimizing her blood pressure and glucose control perioperatively, rather than postponing surgery. Her blood pressure of 160/95 mmHg and glucose of 9.1 mmol/L (164 mg/dL) fall within acceptable ranges that do not require surgical delay according to current guidelines.

Blood Pressure Assessment

Her BP of 160/95 mmHg does not warrant postponing elective surgery. The most recent 2024 ACC/AHA guidelines clearly state that surgery should only be deferred for BP ≥180/110 mmHg 1. Her current reading falls well below this threshold.

• For BP between 160-179/100-109 mmHg, guidelines recommend proceeding with surgery while informing the primary care physician to optimize the antihypertensive regimen 2, 3
• BP <160/100 mmHg is considered optimal for proceeding without delay 2, 4
• The 2024 guidelines give a Class 2b recommendation (may be considered) for deferring surgery only when BP is ≥180/110 mmHg in patients undergoing elevated-risk surgery with cardiovascular risk factors 1

Continue her current antihypertensive medications throughout the perioperative period with one important exception: if she is taking ACE inhibitors or ARBs, these should be held on the day of surgery but restarted postoperatively 2, 3. All other antihypertensives (beta-blockers, calcium channel blockers, clonidine) must be continued to avoid rebound hypertension 1, 3.

Glucose Management

Her glucose of 9.1 mmol/L (164 mg/dL) is within acceptable perioperative range and does not require postponement. The American Diabetes Association recommends a perioperative target glucose range of 5.6-10.0 mmol/L (100-180 mg/dL) 2. Her current glucose falls comfortably within this target.

• The critical threshold for postponing elective surgery is HbA1c >8%, not a single glucose reading 2
• Without knowing her HbA1c, a single glucose of 9.1 mmol/L does not indicate poor long-term control
• Perioperative glucose monitoring should occur every 2-4 hours while NPO 2

Adjust her diabetes medications appropriately for surgery:

• Hold metformin on the day of surgery 2
• Discontinue SGLT2 inhibitors 3-4 days before surgery to prevent euglycemic diabetic ketoacidosis 2
• Give 75-80% of long-acting insulin dose or half of NPH dose 2
• Use basal-bolus insulin coverage perioperatively rather than correction-only insulin, as this significantly reduces complications 2

Why Other Options Are Incorrect

Option A (Postpone for one month) is not indicated. A one-month delay would only be justified if her BP was ≥180/110 mmHg 1, 2. Postponing surgery unnecessarily exposes the patient to prolonged disease burden from whatever condition requires surgery, without meaningful reduction in perioperative risk.

Option C (Order CBC and electrolytes) may be reasonable but is not the primary action needed. While preoperative labs are often obtained, they don't address the core issue of optimizing her chronic conditions. The question asks what you would do given her uncontrolled HTN and DM—the answer is to optimize these conditions, not simply order routine labs.

Option D (Order chest x-ray) is not indicated. There is no evidence presented suggesting pulmonary pathology, heart failure, or other indication for chest imaging. Routine preoperative chest x-rays in asymptomatic patients are not recommended by current guidelines 1.

Intraoperative and Postoperative Targets

Maintain strict hemodynamic parameters during surgery:

• Keep mean arterial pressure ≥60-65 mmHg or systolic BP ≥90 mmHg to reduce myocardial injury risk (Class I recommendation) 1, 3
• In elderly patients with chronic hypertension, consider higher BP targets than younger patients 1

Restart antihypertensive medications as soon as clinically reasonable postoperatively (Class I recommendation) to avoid complications from postoperative hypertension 1, 3. If unable to take oral medications, use IV bridge therapy with nicardipine as first-line 3.

Critical Pitfalls to Avoid

• Never abruptly discontinue beta-blockers or clonidine due to life-threatening rebound hypertension risk 1, 4
• Don't use correction-only insulin perioperatively—basal-bolus regimens significantly reduce complications 2
• Don't forget to discontinue SGLT2 inhibitors 3-4 days preoperatively to prevent euglycemic diabetic ketoacidosis 2
• Avoid overly strict glucose targets—perioperative goals tighter than 4.4-10.0 mmol/L increase hypoglycemia without improving outcomes 2