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Blood Pressure Medicine Side Effects

Abstract

Background: A common practice is not to operate on patients with elevated blood pressure (BP) levels to avoid cardiovascular and cerebrovascular complications. We therefore designed a study to evaluate the effect of prolonged surgery under local anesthesia on BP levels, and to compare the outcome of patients with elevated BP to those with normal BP.

Methods: We studied 121 patients (65 males) with a mean age of 60 [+ or -] 14 years (range 31-89) who were referred for Mohs micrographic surgery (MMS) during 2 consecutive months. Forty six patients had a history of hypertension. Blood pressure was measured in all subjects in the supine position with an automated device 5 times during surgery.

Results: Blood pressure decreased significantly during surgery from 152 [+ or -] 2/85 [+ or -] 1 mm Hg at baseline to 139 [+ or -] 2/79 [+ or -] 1 at the end of the surgery (p < .05). Forty two patients (34%) had elevated BP levels at baseline whereas only 18 patients had these levels at the end of the first stage. There was no difference in surgery outcomes between those with elevated and those with normal BP levels at baseline.

Conclusions: Blood pressure levels decrease during MMS under local anesthesia and the outcome of patients with elevated BP is good. Thus, patients with elevated BP can safely undergo surgery under local anesthesia.

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Introduction

Hypertension is associated with poor outcome after surgery. (1,2) Elevated blood pressure is a major cause of perioperative bleeding and postoperative hematoma. (3) Although Mohs micrographic surgery (MMS) is done under local anesthesia it is a long-lasting surgery. It is sometimes associated with complicated reconstruction and thus any anxiety in the patient can raise the blood pressure. This elevation of blood pressure on top of baseline hypertension is of major concern. The purpose of our study was to evaluate the blood pressure of patients undergoing MMS and their outcome.

Patients and Methods

We studied 121 patients (65 males) with a mean age of 60 [+ or -] 14 years (range 31-89) who were referred for MMS because of skin cancer during the months of June and July 2003. Forty six patients had a history of hypertension and were treated with angiotensin converting enzyme inhibitors (25 patients), calcium antagonists (15 patients), beta blockers (14 patients) and diuretics (12 patients) either as monotherapy or in combination. Blood pressure was measured in all subjects in the supine position with an automated device (Propaq 120EL by Protocol Sys. Inc) 5 times during surgery; when the patient was lying down on the operating table with the maximal expected anxiety (baseline), at the end of the local anesthetics injection (Time 1), at the end of the first stage of surgery when the patient was ready to leave to the room (Time 2), before the beginning of wound reconstruction (Time 3) and at the end of surgery before discharge from the operating room (Time 4).

Results

Blood pressure decreased significantly during the surgery from 152 [+ or -] 2/85 [+ or -] 1 mm Hg at baseline to 136 [+ or -] 2/76 [+ or -] 1 at Time 2, and 139 [+ or -] 2/79 [+ or -] 1 at the end of the surgery (p < 0.05). Forty-two patients (34%) had elevated BP levels at baseline whereas only 18 patients had these levels at Time 2. Seventeen patients had systolic BP greater than 180 mm Hg at baseline whereas only 4 patients had these levels on Time 2. All patients recovered completely. There was no difference in surgery outcomes between those with elevated and those with normal BP levels at baseline.

Discussion

Howell (4) showed that pre-operative history of hypertension is strongly associated with perioperative cardiovascular death. In a recent systematic meta-analysis of 30 observational studies an odds ratio of 1.35 (1.17-1.56) for the association between hypertensive disease and perioperative cardiac outcomes was demonstrated. (5)

The risk of hypertension was also described in dermatologic surgical procedures. (3) Blood pressure control and use of beta-blockers may reduce the perioperative risk associated with hypertension. (6) Recent studies suggest that beta-blockers administered perioperatively may reduce the risk of adverse cardiac events and mortality in patients who have cardiac risk factors and undergo major noncardiac surgery. (6) Despite the clear association between hypertension and perioperative complications, there is little evidence for an association between arterial pressures at admission and perioperative complications. In a study of 676 consecutive patients, hypertension at hospital admission was not associated with perioperative cardiac complications. (7) Howell et al (4) found no association between systolic or diastolic pressure at admission for operation and perioperative cardiovascular death. Physicians usually postpone surgery to control arterial pressure because they believe that low perioperative blood pressure levels will improve perioperative cardiac outcome. Indeed, there is a tendency to treat aggressively perioperative hypertension but there are no long-term, large-scale study data indicating that this treatment affects long-term patient outcomes. (8)

It should be remembered that blood pressure levels tend to increase in the perioperative period because of increased activity or inadequate inhibition of the autonomic nervous system. (9) Stress may also increase blood pressure in the preoperative period (10) and stress reducing techniques may lower blood pressure in these patients. (10) In the present study we showed the blood pressure levels decrease during the surgery without any specific use of antihypertensive agents. Moreover, the outcome was not dependent on blood pressure levels at admission. It seems that the preoperative blood pressure levels do not predict the levels during the surgery. In a recent editorial Spahn et al (11) raised the question whether it is justifiable to postpone surgery when perioperative blood pressure is high. According to our results it seems unjustified to defer surgery because of elevated blood pressure levels. In the present study we showed the effects of perioperative hypertension on MMS. Whether this is also applicable to general surgery should be studied.

References

1. Laslett L. Hypertension. Preoperative assessment and perioperative management. West J Med. 1995;162:215-219.

2. Chung F, Mezei G, Tong D. Pre-existing medical conditions as predictors of adverse events in day-case surgery. Br J Anaesth. 1999;83:262-270.

3. Dzubow LM. Blood pressure as a parameter in dermatologic surgery. Arch Dermatol. 1986;122:1406-1407.

4. Howell SJ, Sear YM, Yeates D, Goldacre M, Sear JW, Foex P. Hypertension, admission blood pressure and perioperative cardiovascular risk. Anaesthesia. 1996;51:1000-1004.

5. Howell SJ, Sear JW, Foex P. Hypertension, hypertensive heart disease and perioperative cardiac risk. Br J Anaesth. 2004; 92:570-583.

6. Auerbach AD, Goldman L. beta-Blockers and reduction of cardiac events in noncardiac surgery: clinical applications. Jama. 2002; 287:1445-1447.

7. Goldman L, Caldera DL. Risks of general anesthesia and elective operation in the hypertensive patient. Anesthesiology. 1979; 50:285-292.

8. Goldberg ME, Larijani GE. Perioperative hypertension. Pharmacotherapy. 1998;18:911-914.

9. Leslie JB. Incidence and aetiology of perioperative hypertension. Acta Anaesthesiol Scand Suppl. 1993;99:5-9.

10. Allen K, Golden LH, Izzo JL, Jr., Ching MI, Forrest A, Niles CR, Niswander PR, Barlow JC. Normalization of hypertensive responses during ambulatory surgical stress by perioperative music. Psychosom Med. 2001;63:487-492.

11. Spahn DR, Priebe HJ. Editorial II: Preoperative hypertension: remain wary? "Yes"--cancel surgery? "No." Br J Anaesth. 2004;92:461-464.

J. Alcalay MD, (a) R. Alkalay MD, (b) E. Grossman MD (c)

a. Mohs Surgery Unit, Assuta Medical Center, Tel-Aviv, Israel

b. Department of Dermatology, Hadassah University Hospital, Faculty of Medicine, Hebrew University, Jerusalem

c. Hypertension Unit, the Chaim Sheba Medical Center, Tel-Hashomer, Israel

Address for Correspondence

Joseph Alcalay MD

19 Weinshall Street, Tel-Aviv, 69413 Israel

e-mail: alcalays@zahav.net.il

Fax: 972-3-6486432

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