The traditional cutoff of deferring surgery if blood pressure is greater than 180/110 is not well supported by contemporary data [1, 2], but many anesthesiologists would be reluctant to take a patient into the operating room for elective surgery with a systolic BP > 180 or a diastolic BP > 110. Some studies show that this may be associated with a modest increase in the risk of perioperative stroke. There are no good data that say, however, that deferring surgery for definitive blood pressure control is superior to acute blood pressure control in the preoperative holding area. Blood pressure risk is a continuum and must be balanced by many factors, including the urgency of surgery. Medications can be given in the preop holding area to ameliorate the high pressure without having to cancel surgery. It is best to work with the anesthesiologist.

There are some surgical procedures (such as facial plastic surgery and intraocular surgery) that should not be done without better control of hypertension because of the risks of increased intraoperative bleeding. On the other hand, acutely lowering blood pressure in patients with certain types of problems, such as patients with high intracranial pressure, is more dangerous than leaving things alone, even if significant hypertension is present. Again, work with your anesthesiology colleagues to optimize blood pressure in the context of the patient’s comorbidities and the planned surgery.

It is important to understand what happens in the intraoperative phase controlled by the anesthesia team. Intraop SBP can average 50 mmHg below ambulatory levels; tight control preop may lead to profound hypotension intraop requiring pressors and extra fluids. Preoperative medication management strategies may minimize the risk of intraoperative hypotension: