What is the best course of action for an elderly female patient with uncontrolled hypertension (HTN) and diabetes mellitus (DM), presenting with elevated blood pressure and hyperglycemia, who is scheduled for elective surgery?

Proceed with Surgery and Order Routine Preoperative Labs

This patient's blood pressure of 160/95 mmHg and glucose of 9.1 mmol/L (164 mg/dL) do not require postponing elective surgery or adjusting medications preoperatively—proceed with surgery after ordering CBC and electrolytes (Option C). 1, 2

Blood Pressure Assessment

The patient's BP of 160/95 mmHg falls well below the threshold for surgical postponement:

• Surgery should proceed for BP <180/110 mmHg according to joint guidelines from the Association of Anaesthetists and British Hypertension Society 1
• The American College of Cardiology and American Heart Association confirm that surgery should only be deferred when BP ≥180/110 mmHg 2, 3
• For BP between 160-179/100-109 mmHg, guidelines recommend proceeding with surgery while informing the primary care physician postoperatively to optimize the antihypertensive regimen 2, 3

The disparity between primary care thresholds (160/100 mmHg) and surgical thresholds (180/110 mmHg) exists because there is no evidence that perioperative blood pressure reduction affects cardiovascular event rates beyond what would be expected in a single month. 1 Postponing surgery for one month (Option A) would expose the patient to a 1% relative increase in cardiovascular risk simply from aging, without proven benefit from BP optimization. 1

Glucose Assessment

The glucose of 9.1 mmol/L (164 mg/dL) is acceptable for proceeding with surgery:

• The American Diabetes Association recommends a perioperative target glucose range of 5.6-10.0 mmol/L (100-180 mg/dL) 2
• This patient's glucose falls within the acceptable range
• The critical threshold for postponing elective surgery is HbA1c >8%, not a single glucose reading 2

Adjusting medications preoperatively (Option B) is unnecessary and potentially harmful, as medication changes require time to assess efficacy and could destabilize the patient.

Appropriate Preoperative Testing

Order CBC and electrolytes before surgery (Option C is correct):

• These are standard preoperative labs for elderly patients with hypertension and diabetes
• Electrolytes are particularly important given likely diuretic use for hypertension 4, 5
• Baseline renal function assessment is essential in diabetic patients 5

CXR (Option D) is not routinely indicated unless there are specific cardiopulmonary symptoms or findings on history/physical examination that warrant it.

Medication Management Strategy

For the perioperative period:

• Continue most antihypertensive medications throughout the perioperative period 2, 3
• Hold ACE inhibitors/ARBs on the day of surgery but restart postoperatively 2, 3
• Never abruptly discontinue beta-blockers or clonidine due to life-threatening rebound hypertension risk 2, 3
• Hold metformin on the day of surgery 2
• Discontinue SGLT2 inhibitors 3-4 days before surgery to prevent euglycemic diabetic ketoacidosis 2

Critical Pitfalls to Avoid

• Do not postpone surgery unnecessarily—this patient's BP and glucose are within acceptable ranges for proceeding 1, 2
• Do not make last-minute medication adjustments—perioperative medication management should follow established protocols, not reactive changes 2, 3
• Do not aim for overly strict glucose targets perioperatively—targets tighter than 4.4-10.0 mmol/L increase hypoglycemia without improving outcomes 2
• Do not forget to communicate with the primary care physician postoperatively about optimizing the antihypertensive regimen for long-term management 1