Arterial Hypertension, a Frequent Comorbidity in Diabetes: the Perioperative Management

Arterial hypertension and diabetes mellitus frequently coexist. Preexisting arterial hypertension is a main reason for postponing surgery in diabetic patients. Hypertension is a risk factor for cardiovascular complications during the perioperative period. The term peri-operative generally refers to the three phases of surgery: pre-operative, intra-operative, and post-operative. Sympathetic activation during the induction of anesthesia can cause increases in blood pressure by 20 to 30 mm Hg and increases in heart rate by 15-20 beats per minute in patients with normal blood pressure values. These values are higher in patients with untreated hypertension. The effect of chronic hypertension on perioperative risk is determined primarily by the presence of target organ damage, coronary artery disease, stroke, heart failure and renal failure, all of which are known to affect perioperative morbidity and mortality. There are no randomized clinical trial data showing what the optimal blood pressure should be at the time of surgery. In patients with grade 1 or 2 hypertension, there is no evidence of benefit from delaying surgery to optimize therapy. In such cases, antihypertensive medications should be continued during the perioperative period. Most antihypertensive drugs should be continued to the day of surgery and restart as soon as possible (when the patient will be able to swallow). Only agents that affect the renin-angiotensin-aldosterone system should be canceled (angiotensin-converting enzyme inhibitors and angiotensin receptor blockers). Regarding beta-blockers, the treatment should ideally be initiated between 30 days and at least 2 days before surgery, starting at a low dose, and should be continued post-operatively. The target is a resting heart rate 60-70 bpm and systolic blood pressure > 100 mm Hg.