Penatalaksanaan Hipertensi Preoperatif

Penatalaksanaan
Hipertensi
Preoperatif

Objectives of these Guidelines
To describe how to assess perioperative cardiac risk using
clinical risk factors and type of surgical procedure
To describe a stepwise approach for pre-operative
cardiac risk assesment
To address the impact of various co-morbidities on
perioperative risk
To describe how to reduce cardiac risk
To be easy to use for practitioners

Arterial hypertension
On special consideration in terms of cardiovascular
pre-operative assessment

ACEIs or ARBs
 The lack of speciﬁc data on angiotensin-receptorblockers (ARBs),
the following recommendations apply to ACEIs and ARBs, given
their numerous common pharmacological properties.
 Peri-operative use of ACEIs or ARBs carries a risk of severe
hypotension under anaesthesia, in particular following induction
and concomitant beta-blocker use. Hypotension is less frequent
when ACEIs are discontinued the day before surgery.
 Although this remains debatable, ACEIs withdrawal should be
considered 24 hours before surgery when they are prescribed for
hypertension.They should be resumed after surgery as soon as
blood volume and pressure are stable.

ACEIs or ARBs
 The risk of hypotension is at least as high with ARBs as with
ACEIs, and the response to vasopressors may be impaired.
 In patients with LV systolic dysfunction, who are in a stable clinical
condition, it seems reasonable to continue treatment with ACEIs
under close monitoring during the peri-operative period.
 When LV dysfunction is discovered during pre-operative
evaluation in untreated patients in a stable condition, surgery
should if possible be postponed, to allow for diagnosis of the
underlying cause and the introduction of ACEIs and beta-blockers.

Calcium channel blockers
 The effect of calcium channel blockers on the balance between
myocardial oxygen supply and demand makes them theoretically
suitable for risk-reduction strategies. It is necessary to distinguish
between dihydropyridines, which do not act directly on heart rate,
and diltiazem or verapamil, which lower the heart rate.
 There was a signiﬁcant reduction in the number of episodes of
myocardial ischaemia and supraventricular tachycardia (SVT) in the
pooled analyses; however, the decrease in mortality and
myocardial infarction reached statistical signiﬁcance only when both
endpoints were combined in a composite of death and/or
myocardial infarction (relative risk 0.35; 95% CI 0.08– 0.83; P ,
0.02). Subgroup analyses favoured diltiazem.

Calcium channel blockers
 Another study in 1000 patients undergoing acute or elective aortic
aneurysm surgery showed that dihydropyridine use was
independently associated with an increased incidence of peri-
operative mortality.
 The use of short-acting dihydropyridines—in particular, nifedipine
capsules—should be avoided.
 Thus, although heart rate-reducing calcium channel blockers are not
indicated in patients with heart failure and systolic dysfunction, the
continuation or introduction of heart rate-reducing calcium channel
blockers may be considered in patients who do not tolerate beta-
blockers.
 Additionally, calcium channel blockers should be continued during
non-cardiac surgery in patients with vasospastic angina

Alpha2 receptor agonists
 Clonidine did not reduce the rate of death or non-fatal myocardial
infarction in general, or in patients undergoing vascular surgery
(relative risk 1.08; 95% Cl 0.93– 1.26; P ¼ 0.29).
 On the other hand, clonidine increased the risk of clinically
importanthypotension (relative risk 1.32; 95% Cl 1.24– 1.40; P ,
0.001) and non-fatal cardiac arrest (relative risk 3.20; 95% Cl 1.17–
8.73; P ¼ 0.02).
 Therefore, alpha receptor agonists should not be administered to
patients undergoing non-cardiac surgery.

Diuretics
 diuretics for hypertension should be continued to the day of surgery
and resumed orally when possible.
 If blood pressure reduction is required before oral therapy can be
continued, other antihypertensive agents may be considered.
 In heart failure, dosage increase should be considered if symptoms or
signs of ﬂuid retention are present.
 Dosage reduction should be considered in patients with hypovolaemia,
hypotension, or electrolyte disturbances.
 volume status in patients with heart failure should be monitored
carefully and optimized by loop diuretics or ﬂuids.
 the use of Kand Mg -sparing aldosterone antagonists reduces therisk
of mortality in severe heart failure.

 Postponing necessary surgery is usually not warranted in patients
with grade 1 or 2 hypertension, whereas in those with an SBP
>_180 mmHg and/or DBP >_110 mmHg, deferring the intervention
until BP is reduced or controlled is advisable, except for
emergency situations. What seems to be also important is to avoid
large perioperative BP fluctuations.
 This approach is supported by the findings from a recent RCT that
has shown that in patients undergoing abdominal surgery, an
individualized intraoperative treatment strategy, which kept BP
values within a 10% difference from the preoperative office SBP,
resulted in reduced risk of postoperative organ dysfunction

 recently, the question has been raised whether RAS blockers
should be discontinued before surgery to reduce the risk of
intraoperative hypotension.
 Preoperative discontinuation of these drugs has also been
supported by a recent international prospective cohort study, in a
heterogenous group of patients, in which withholding ACE
inhibitors or ARBs 24 h before non-cardiac surgery was associated
with a significant reduction in CV events and mortality 30 days
after the intervention.

2018 ESC/ESH Hypertension Guidelines 11
Classification of office BP and
grade
definitions of hypertension
Williams, Mancia et al., J Hypertens 2018;36:1953-2041 and Eur Heart J 2018;39:3021-3104
Category Systolic (mmHg) Diastolic (mmHg)
Optimal < 120 and < 80
Normal 120–129 and/or 80–84
High normal 130–139 and/or 85–89
Grade 1 hypertension 140–159 and/or 90–99
Grade 2 hypertension 160–179 and/or 100–109
Grade 3 hypertension ≥ 180 and/or ≥ 110
Isolated systolic hypertension ≥ 140 and < 90

Factors influencing CV risk in patients with hypertension - 1
Demographic characteristics and laboratory parameters
Sex (men > women)
Age
Smoking – current or past history
Total cholesterol and HDL-C
Uric acid
Diabetes
Overweight or obesity
Family history of premature CVD (men aged < 55 years and women aged < 65 years)
Family or parental history of early onset hypertension
Early onset menopause
Sedentary lifestyle
Psychosocial and socioeconomic factors
Heart rate (resting values > 80 beats per min)

Asymptomatic HMOD
Arterial stiffening: Pulse pressure (in older people) ≥ 60 mmHg
Carotid–femoral PWV > 10 m/s
ECG LVH
Echocardiographic LVH
Microalbuminuria or elevated albumin–creatinine ratio
Moderate CKD with eGFR 30–59 mL/min/1.73 m2 (BSA)
Ankle−brachial index < 0.9
Advanced retinopathy: haemorrhages or exudates, papilloedema

Established CV or renal disease
Cerebrovascular disease: ischaemic stroke, cerebral haemorrhage, TIA
CAD: myocardial infarction, angina, myocardial revascularization
Presence of atheromatous plaque on imaging
Heart failure, including HFpEF
Peripheral artery disease
Atrial fibrillation
Severe CKD with eGFR < 30 mL/min/1.73 m2

10-year CV risk categories (SCORE system)
• A calculated 10-year SCORE of < 1%
Very high risk
People with any of the following:
Documented CVD, either clinical or unequivocal on imaging.
• Clinical CVD includes acute myocardial infarction, acute coronary syndrome, coronary or other
arterial revascularization, stroke, TIA, aortic aneurysm and PAD.
• Unequivocal documented CVD on imaging includes significant plaque (i.e. ≥ 50% stenosis)
on angiography or ultrasound. It does not include increase in carotid intima-media thickness.
• Diabetes mellitus with target organ damage, e.g. proteinuria or a with a major risk factor
such as grade 3 hypertension or hypercholesterolaemia
• Severe CKD (eGFR < 30 mL/min/1.73 m2)
• A calculated 10-year SCORE of ≥ 10%
High risk
People with any of the following:
• Marked elevation of a single risk factor, particularly cholesterol > 8 mmol/L (> 310 mg/dL)
e.g. familial hypercholesterolaemia, grade 3 hypertension (BP ≥ 180/110 mmHg)
• Most other people with diabetes mellitus (except some young people with type 1 diabetes
mellitus and without major risk factors, that may be moderate risk)
• Hypertensive LVH
• Moderate CKD (eGFR 30–59 mL/min/1.73 m2)
• A calculated 10-year SCORE of 5–10%
Moderate risk
People with:
• A calculated 10-year SCORE of 1% to < 5%
• Grade 2 hypertension
• Many middle-aged people belong to this category
Low risk
People with:

Initiation of BP-lowering treatment
(lifestyle changes and medication) at different initial office BP levels
High normal BP Grade 1 hypertension Grade 2 hypertension Grade 3 hypertension
BP 130-139 / 85-89 BP 140-159 / 90-99 BP 160-179 / 100-109 BP ≥ 180/ 110
Lifestyle advice Lifestyle advice Lifestyle advice Lifestyle advice
Immediate drug
treatment in high
or very high risk
patients with CVD,
renal disease or
HMOD
Consider drug
treatment in very
high risk patients
with CVD,
especially CAD
Immediate drug
treatment in all
patients
Immediate drug
treatment in all
patients
Drug treatment in
low-moderate risk
patients without
CVD, renal disease
or HMOD
after 3-6 months of
lifestyle intervention
if BP not controlled
Aim for BP control
within 3 months
Aim for BP control
within 3 months

Summary of office BP thresholds for treatment
threshold
Age group
Office SBP treatment threshold (mmHg) Office DBP
treatment
(mmHg)
Hypertension + Diabetes + CKD + CAD + Stroke/TIA
18−65 years ≥ 140 ≥ 140 ≥ 140 ≥ 140 ≥ 140 ≥ 90
65−79 years ≥ 140 ≥ 140 ≥ 140 ≥ 140 ≥ 140 ≥ 90
≥ 80 years ≥ 160 ≥ 160 ≥ 160 ≥ 160 ≥ 160 ≥ 90
Office DBP
treatment
threshold
(mmHg)
≥ 90 ≥ 90 ≥ 90 ≥ 90 ≥ 90

Core drug-treatment strategy for
uncomplicated hypertension
The core algorithm is also appropriate for most patients with HMOD, cerebrovascular disease, diabetes, or PAD

Drug-tr
Hypertension and CAD
Core drug-treatmen t strategy for uncomplicated hypertensio n
eatment strategies
Hypertension and CKD
Hypertension and HRrEF Hypertension and AF

Office BP treatment target range
treatment
Age group
Office SBP treatment target ranges (mmHg)
Office DBP
target range
(mmHg)
Hypertension + Diabetes + CKD + CAD + Stroke/TIA
18−65 years
Target to 130
or lower if
tolerated
Not < 120
Target to 130
or lower if
tolerated
Not < 120
Target to
< 140 to 130
if tolerated
Target to 130
or lower if
tolerated
Not < 120
Target to 130
or lower if
tolerated
Not < 120
70-79
65−79 years
Target to
< 140 to 130
if tolerated
Target to
< 140 to 130
if tolerated
Target to
< 140 to 130
if tolerated
Target to
< 140 to 130
if tolerated
Target to
< 140 to 130
if tolerated
70-79
≥ 80 years
Target to
< 140 to 130
if tolerated
Target to
< 140 to 130
if tolerated
Target to
< 140 to 130
if tolerated
Target to
< 140 to 130
if tolerated
Target to
< 140 to 130
if tolerated
70-79
Office DBP
treatment target
range(mmHg)
70-79 70-79 70-79 70-79 70-79

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