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Hypertension: A Changing Role for Anesthesiologists.

In respect of patients with arterial hypertension presenting for surgery, the role of anesthesiologists is changing. Initially, the role had been purely to consider the cardiovascular risk of surgery in such patients and inform them and the surgeons of the risk and the best preoperative approach. Today this role is expanding: anesthesiologists play an increasing role as perioperative physicians. This is particularly important in respect of patients with arterial hypertension because worldwide over 1 billion people suffer from hypertension. With the increasing age and the greater sedentarity of the population, the prevalence of hypertension will continue to rise toward 1.5 billion by 2025.1 Undiagnosed hypertension is frequent, and its treatment is often suboptimal, particularly in subSaharan Africa.2 This is also the case in the Indian subcontinent, to cite only 2 examples. High-income countries suffer from the same problem as highlighted in a recent report from the British Heart Foundation. It states that nearly 30% of the population suffers from arterial hypertension. For 10 patients diagnosed with hypertension, there are another 7 with undiagnosed hypertension.3 The diagnosis of hypertension can also be delayed in the United States.4,5 Thus, the preoperative assessment of patients offers an opportunity to identify those with arterial hypertension thereby influencing their shortand long-term management. Before the introduction of efficacious drug therapy, hypertension was a major cause of perioperative mortality, as high as 30% in a study by Sprague in 1929. Fifty years ago, there was still widespread concern that antihypertensive drugs impaired the maintenance of homeostasis during anesthesia and surgery resulting in cardiovascular collapse. It was generally accepted that their administration should be stopped before surgery. All the antihypertensive agents used in the 1960s (bethanidine, bretylium, guanethidine, methyldopa, reserpine) figure in a “danger list” for cardiovascular collapse in surgical patients. Later β-blockers were regarded as potentially dangerous in surgical patients, and it was recommended to stop them before surgery. Adverse effects of maintaining drug therapy, including β-adrenoceptor blockers, were disproved in very detailed hemodynamic studies in severely hypertensive patients undergoing surgery under general anesthesia.6 Thereafter, it became customary to continue the antihypertensive medication throughout the perioperative period. Further studies in the 1980s confirmed that maintenance of antihypertensive medication did not cause significant hypotension.7 With the introduction of effective drugs for the treatment of hypertension and the development of guidelines for the management of hypertensive patients in the population, the role of arterial hypertension as a risk factor for perioperative complications of anesthesia and surgery declined. Indeed several frequently used cardiovascular risk indices do not include hypertension as a risk factor for cardiovascular complications of surgery.8 Arterial hypertension is not mentioned in the 2014 American College of Cardiology/American Heart Association (ACC/ AHA) guideline for the management of patients with cardiovascular disease presenting for surgery,9 only briefly mentioned in the 2014 European Guideline on the same topic,10 and not discussed at all in the 2018 European Society of Cardiology/European Society of Hypertension (ESC/ESH) guideline on hypertension.1 As a result, a recent guideline for the management of hypertensive patients presenting for surgery11 Hypertension: A Changing Role for Anesthesiologists