Skip to main content
SpringerLink
Log in

Perioperative Cardiac Surgery Hypertension

  • Chapter
  • First Online:
Disorders of Blood Pressure Regulation

Part of the book series: Updates in Hypertension and Cardiovascular Protection ((UHCP))

Abstract

Perioperative hypertension, independent of preexisting hypertension, is common, can have a large impact on surgical outcomes, and, importantly, occurs in patients without any prior history of hypertension. The etiology of perioperative HTN is multifactorial and mechanistically discrete from that of nonsurgical hypertension. Common perturbations and responses to the surgical experience including rapid intravascular volume shifts, changes in sympathetic tone due to anesthetic drugs, direct surgical stimulation, autonomic stress responses, and pain all contribute to the hemodynamic instability commonly encountered during the care of surgical patients. Unlike the consequences of nonsurgical HTN that take years to decades to manifest, those secondary to perioperative BP are appreciated on time scales ranging from minutes to days.

Defining a “target” BP during the intraoperative or postoperative period is a routine part of perioperative patient care but despite the ubiquity of this clinical effort, there is surprisingly little objective evidence on the appropriate clinical goals. Uncertainty exists regarding understanding of optimal clinical goals for perioperative blood pressure (BP) management in patients undergoing cardiac surgery as well as the consequences of achieving or failing to achieve those goals. In this setting, preoperative hypertension (HTN) is predictive of poor postoperative outcomes with a growing appreciation that heretofore clinically acceptable changes in intraoperative BP may also independently be associated with short- and long-term adverse outcomes. Finally, the impact of postoperative BP on outcomes following cardiac surgery has been shown to be independently associated with adverse outcome.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution

Institutional subscriptions

References

  1. Kearney PM, Whelton M, Reynolds K et al (2005) Global burden of hypertension: analysis of worldwide data. Lancet 365:217–223

    Article  PubMed  Google Scholar 

  2. Ezzati M, Oza S, Danaei G, Murray CJ (2008) Trends and cardiovascular mortality effects of state-level blood pressure and uncontrolled hypertension in the United States. Circulation 117:905–914

    Article  PubMed  Google Scholar 

  3. Wang TJ, Vasan RS (2005) Epidemiology of uncontrolled hypertension in the United States. Circulation 112:1651–1662

    Article  PubMed  Google Scholar 

  4. Mozaffarian D, Benjamin EJ, Go AS et al (2015) Heart disease and stroke statistics—2015 update: a report from the American Heart Association. Circulation 131:e29–e322

    Article  PubMed  Google Scholar 

  5. Huffman MD, Capewell S, Ning H et al (2012) Cardiovascular health behavior and health factor changes (1988-2008) and projections to 2020: results from the National Health and nutrition examination surveys. Circulation 125:2595–2602

    Article  PubMed Central  PubMed  Google Scholar 

  6. Go AS, Mozaffarian D, Roger VL et al (2013) Heart disease and stroke statistics—2013 update: a report from the American Heart Association. Circulation 127:e6–e245

    Article  PubMed  Google Scholar 

  7. Heidenreich PA, Trogdon JG, Khavjou OA et al (2011) Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Circulation 123:933–944

    Article  PubMed  Google Scholar 

  8. Hollenberg M, Mangano DT, Browner WS et al (1992) Predictors of postoperative myocardial ischemia in patients undergoing noncardiac surgery. The Study of Perioperative Ischemia Research Group. JAMA 268:205–209

    Article  CAS  PubMed  Google Scholar 

  9. Mangano DT, Layug EL, Wallace A, Tateo I (1996) Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. Multicenter study of perioperative ischemia research group. N Engl J Med 335:1713–1720

    Article  CAS  PubMed  Google Scholar 

  10. Mangano DT (1999) Assessment of the patient with cardiac disease: an anesthesiologist’s paradigm. Anesthesiology 91:1521–1526

    Article  CAS  PubMed  Google Scholar 

  11. Aronson S, Boisvert D, Lapp W (2002) Isolated systolic hypertension is associated with adverse outcomes from coronary artery bypass grafting surgery. Anesth Analg 94:1079–1084

    Article  PubMed  Google Scholar 

  12. Nikolov NM, Fontes ML, White WD et al (2010) Pulse pressure and long-term survival after coronary artery bypass graft surgery. Anesth Analg 110:335–340

    Article  PubMed  Google Scholar 

  13. Fontes ML, Aronson S, Mathew JP et al (2008) Pulse pressure and risk of adverse outcome in coronary bypass surgery. Anesth Analg 107:1122–1129

    Article  PubMed  Google Scholar 

  14. Aboyans V, Frank M, Nubret K et al (2008) Heart rate and pulse pressure at rest are major prognostic markers of early postoperative complications after coronary bypass surgery. Eur J Cardiothorac Surg 33:971–976

    Article  PubMed  Google Scholar 

  15. Benjo A, Thompson RE, Fine D et al (2007) Pulse pressure is an age-independent predictor of stroke development after cardiac surgery. Hypertension 50:630–635

    Article  CAS  PubMed  Google Scholar 

  16. Aronson S, Fontes ML, Miao Y, Mangano DT (2007) Risk index for perioperative renal dysfunction/failure: critical dependence on pulse pressure hypertension. Circulation 115:733–742

    Article  PubMed  Google Scholar 

  17. Reich DL, Bennett-Guerrero E, Bodian CA et al (2002) Intraoperative tachycardia and hypertension are independently associated with adverse outcome in noncardiac surgery of long duration. Anesth Analg 95:273–277

    PubMed  Google Scholar 

  18. Aronson S, Stafford-Smith M, Phillips-Bute B et al (2010) Intraoperative systolic blood pressure variability predicts 30-day mortality in aortocoronary bypass surgery patients. Anesthesiology 113:305–312

    Article  CAS  PubMed  Google Scholar 

  19. Aronson S, Dyke CM, Levy JH et al (2011) Does perioperative systolic blood pressure variability predict mortality after cardiac surgery? An exploratory analysis of the ECLIPSE trials. Anesth Analg 113:19–30

    Article  PubMed  Google Scholar 

  20. Aronson S (2014) Perioperative hypertensive emergencies. Curr Hypertens Rep 16:448

    Article  PubMed  Google Scholar 

  21. Cheung AT (2006) Exploring an optimum intra/postoperative management strategy for acute hypertension in the cardiac surgery patient. J Card Surg 21(Suppl 1):S8–S14

    Article  PubMed  Google Scholar 

  22. Chobanian AV, Bakris GL, Black HR et al (2003) The seventh report of the joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report. JAMA 289:2560–2572

    Article  CAS  PubMed  Google Scholar 

  23. Oparil S, Aronson S, Deeb GM et al (1999) Fenoldopam: a new parenteral antihypertensive: consensus roundtable on the management of perioperative hypertension and hypertensive crises. Am J Hypertens 12:653–664

    Article  CAS  PubMed  Google Scholar 

  24. Vuylsteke A, Feneck RO, Jolin-Mellgard A et al (2000) Perioperative blood pressure control: a prospective survey of patient management in cardiac surgery. J Cardiothorac Vasc Anesth 14:269–273

    Article  CAS  PubMed  Google Scholar 

  25. Goldberg ME, Weaver FA (2007) Strategies for managing perioperative hypertension. Crit Care Clin 23(Suppl 1):7–21

    CAS  PubMed  Google Scholar 

  26. Balzer F, Aronson S, Treskatsch S et al (2015) Poor post-operative blood pressure control in cardiac surgery patients is associated with acute kidney injury and death. Abstract SCA Annual Meeting, 2015

    Google Scholar 

  27. Immink RV, van den Born BJ, van Montfrans GA et al (2004) Impaired cerebral autoregulation in patients with malignant hypertension. Circulation 110(15):2241–2245

    Article  PubMed  Google Scholar 

  28. Toyoda K, Fujii K, Ibayashi S et al (1998) Attenuation and recovery of brain stem autoregulation in spontaneously hypertensive rats. J Cereb Blood Flow Metab 18(3):305–310

    Article  CAS  PubMed  Google Scholar 

  29. Ono M, Arnaoutakis GJ, Fine DM et al (2013) Blood pressure excursions below the cerebral autoregulation threshold during cardiac surgery are associated with acute kidney injury. Crit Care Med 41:464–471

    Article  PubMed Central  PubMed  Google Scholar 

  30. Imoto K, Hiro T, Fujii T (2005) Longitudinal structural determinants of atherosclerotic plaque vulnerability: a computational analysis of stress distribution using vessel and three dimensional intravascular ultrasound imaging. J Am Coll Cardiol 46:1507–1515

    Article  PubMed  Google Scholar 

  31. Lee KW, Blann AD, Lip GY (2004) High pulse pressure and nondipping circadian blood pressure in patients with coronary artery disease: relationship to thrombogenesis and endothelial damage/dysfunction. Am J Hypertens 18:104–115

    Article  Google Scholar 

  32. Brienza N, Giglio MT, Marucci M, Fiore T (2009) Does perioperative hemodynamic optimization protect renal function in surgical patients? A meta-analytic study. Crit Care Med 37:2079–2090

    Article  PubMed  Google Scholar 

  33. Gurgel ST, do Nascimento P Jr (2011) Maintaining tissue perfusion in high-risk surgical patients: a systematic review of randomized clinical trials. Anesth Analg 112:1384–1391

    Article  PubMed  Google Scholar 

  34. O’Rourke MF, Safar ME (2005) Relationship between aortic stiffening and microvascular disease in brain and kidney: cause and logic of therapy. Hypertension 46:200–204

    Article  PubMed  Google Scholar 

  35. Hennein HA, Ebba H, Rodriguez JL et al (1994) Relationship of the proinflammatory cytokines to myocardial ischemia and dysfunction after uncomplicated coronary revascularization. J Thorac Cardiovasc Surg 108:626–635

    CAS  PubMed  Google Scholar 

  36. Kobzar G, Mardla V, Rätsep I, Samel N (2006) Platelet activity before and after coronary artery bypass grafting. Platelets 17:289–291

    Article  CAS  PubMed  Google Scholar 

  37. Aronson S, Phillips-Bute B, Stafford Smith M et al (2013) The association of post-cardiac surgery acute kidney injury with intraoperative systolic blood pressure hypotension. Anesthesiol Res Pract 2013:174091. doi:10.1155/2013/174091

    PubMed Central  PubMed  Google Scholar 

  38. Aronson S, Levy JH, Lumb PD et al (2014) Impact of perioperative blood pressure variability on health resource utilization after cardiac surgery: an analysis of the ECLIPSE trials. J Cardiothorac Vasc Anesth 28(3):579–585

    Article  PubMed  Google Scholar 

  39. Towne JB, Bernhard VM (1980) The relationship of postoperative hypertension to complications following carotid endarterectomy. Surgery 88:575–580

    CAS  PubMed  Google Scholar 

  40. Halpern NA, Goldberg M, Neely C et al (1992) Postoperative hypertension: a multicenter, prospective, randomized comparison between intravenous nicardipine and sodium nitroprusside. Crit Care Med 20:1637–1643

    Article  CAS  PubMed  Google Scholar 

  41. Gal TJ, Cooperman LH (1975) Hypertension in the immediate postoperative period. Br J Anaesth 47:70–74

    Article  CAS  PubMed  Google Scholar 

  42. Wallach R, Karp RB, Reves JG et al (1980) Pathogenesis of paroxysmal hypertension developing during and after coronary bypass surgery: a study of hemodynamic and humoral factors. Am J Cardiol 46:559–565

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Anesthesiology, Duke University, 103 Baker House, Durham, NC, 27710, USA

    Solomon Aronson MD, MBA, FACC, FCCP, FAHA, FASE

Authors
  1. Solomon Aronson MD, MBA, FACC, FCCP, FAHA, FASE
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Solomon Aronson MD, MBA, FACC, FCCP, FAHA, FASE .

Editor information

Editors and Affiliations

  1. Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon

    Adel E. Berbari

  2. Emeritus Professor of Medicine, University of Milano-Bicocca, Monza, Italy

    Giuseppe Mancia

Rights and permissions

Reprints and permissions

Copyright information

© 2018 Springer International Publishing AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Aronson, S. (2018). Perioperative Cardiac Surgery Hypertension. In: Berbari, A., Mancia, G. (eds) Disorders of Blood Pressure Regulation. Updates in Hypertension and Cardiovascular Protection. Springer, Cham. https://doi.org/10.1007/978-3-319-59918-2_14

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-59918-2_14

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-59917-5

  • Online ISBN: 978-3-319-59918-2

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation