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Screening for High Blood Pressure in the Perioperative Setting

The Role of Anesthesiologists in Future Cardiovascular Risk Management

Kertai, Miklos D. MD, PhD*; Gan, Tong J. MD, MHS, FRCA

doi: 10.1213/ANE.0000000000001014
Editorials: Editorial
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From the *Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina; and Department of Anesthesiology, Stony Brook Medicine, Stony Brook, New York.

Accepted for publication August 21, 2015.

Funding: None.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Tong J. Gan, MD, MHS, FRCA, Department of Anesthesiology, Stony Brook University, Stony Brook, NY 11794. Address e-mail to tong.gan@stonybrookmedicine.edu.

Hypertension is a major modifiable risk factor for cardiovascular disease that affects approximately 80 million (32.6%) adults in the United States. The incidence is projected to increase to approximately 38% by 2030.1 According to the National Health and Nutrition Examination Survey data from 2009 to 2012, only 54% of hypertensive adults in the United States had their condition under control; 77% were currently treated; 83% were aware of their condition and 17% were undiagnosed.2 The economic impact of morbidity and mortality resulting from hypertension is substantial. The additional health care costs exceeded $70 billion in 2010 and are expected to soar to approximately $200 billion by 2030.3,4

Early diagnosis and treatment of hypertension significantly reduce morbidity and mortality and the associated health care costs.5 Persons with high blood pressure have been reported to benefit from evidence-based guidelines that combine lifestyle changes with targeted antihypertensive medication use.5 Therefore, the U.S. Preventive Services Task Force recommends to begin hypertension screening at 18 years of age, and at regular checkups thereafter, to identify adults at an increased risk for cardiovascular disease because of high blood pressure.6

In the September 2015 issue of Anesthesia & Analgesia, Schonberger et al.7 reported the results of their retrospective study based on the electronic health records of veterans who had surgery at any Department of Veterans Affairs heath care facility between September 1, 2006, and August 31, 2011. A total of 385,790 unique patients were identified for potential inclusion in this study. Of these, 215,621 had blood pressure data from the preoperative period, the day of surgery, and the year after surgery. These patients comprised the cohort for predictive modeling. These patients were then evaluated for prevalence of poorly controlled outpatient clinic blood pressure in the year after surgery. By using increasingly complex prediction models, the investigators also analyzed perioperative blood pressure data and a broad spectrum of other clinical and demographic data to identify patients who were likely to maintain increased blood pressures during the year after surgery.

The results of the study showed that 26% of the study population had poorly controlled blood pressure during the year after surgery, including 14% with no known history of hypertension or treatment for hypertension. Predictive modeling showed marginal, and clinically trivial, improvements in performance when a broad range of clinical and administrative data were added to a model that used preoperative blood pressure alone. Indeed, a simple decision rule that used a blood pressure referral threshold ≥150/95 mm Hg from 2 preoperative readings was able to identify a subset of patients (approximately 17% of the national cohort) who were more likely to demonstrate increased blood pressure during the year after surgery. Further, 4 of 5 patients who did not meet this screening criterion demonstrated normal blood pressure in the outpatient clinic during follow-up appointments.

On the basis of these findings, the authors concluded that preoperative blood pressure measurements can serve as a predictor of increased blood pressure during the year after surgery. Applying additional clinical and administrative data to clinical prediction models of increased postoperative blood pressure showed only marginal improvement in guiding referral decisions.

Unlike most studies on the perioperative period, which focus on outcomes directly attributable to the surgical encounter, this study highlights a unique potential role for anesthesiologists in identifying patients with poorly controlled hypertension during the perioperative period and coordinating their care to prevent future cardiovascular complications and mortality. With our increasing focus on our role as perioperative physicians, the study demonstrates that preoperative screening is an opportunity to identify patients with modifiable cardiovascular risk factors such as hypertension. Many studies have shown that adequate treatment of hypertension in the ambulatory setting is associated with a reduced risk for future cardiovascular complications. Perhaps care plans associated with the perioperative surgical home can consider long-term health assessment that goes well beyond concerns about the immediate surgical procedure.

As noted by the authors, this study has some inherent limitations. Given the study population and design of the study, these include (1) limited generalizability of the findings to other non-U.S. veteran subjects; (2) potential differences in the predictive performance of the risk index developed in this study, when it is used in other non-U.S. veteran surgical cohorts; (3) lack of standardized blood pressure collection methods; (4) the decision not to investigate how the results of this study might have been influenced by the change in the definition of high blood pressure according to the Eighth Joint National Committee guidelines5; (5) the potential risk for inaccurate clinical and administrative data; and (6) lack of data on type of blood pressure counseling or referral intervention that would be acceptable to both patients and physicians.

The report by Schonberger et al. shows that perioperative screening for hypertension is a unique opportunity to intervene and potentially modify the long-term cardiovascular risk factors. Anesthesiologists have a role in coordinating perioperative care to improve blood pressure control in surgery patients at risk for future cardiovascular morbidity and mortality. When confirmed by large-scale prospective studies, these findings could become a key element in the evolving concept of the perioperative surgical home care plans for managing patients with high blood pressure or poorly controlled blood pressure.

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DISCLOSURES

Name: Miklos D. Kertai, MD, PhD.

Contribution: This author helped write the manuscript.

Attestation: Miklos D. Kertai approved the final version of the manuscript.

Name: Tong J. Gan, MD, MHS, FRCA.

Contribution: This author helped write the manuscript.

Attestation: Tong J. Gan approved the final version of the manuscript.

RECUSE NOTEDr. Tong J. Gan is the Section Editor for Ambulatory Anesthesiology and Perioperative Management for Anesthesia & Analgesia. This manuscript was handled by Dr. Steven L. Shafer, Editor-in-Chief, and Dr. Gan was not involved in any way with the editorial process or decision.

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