Perioperative Blood Pressure Management in Patient with Multiple Comorbidities

Case at a Glance

A 53-year-old male with polycythemia vera, controlled type 2 diabetes mellitus, and hypertension presents with poorly controlled blood pressure prior to scheduled rotator cuff surgery. Patient discontinued amlodipine without medical supervision due to gingival hyperplasia and peripheral edema.

Patient's Story

The patient is a 53-year-old male weighing approximately 250 pounds with a medical history significant for polycythemia vera, well-controlled type 2 diabetes mellitus, and hypertension. He was scheduled for elective rotator cuff repair surgery. His blood pressure had been well-controlled on combination therapy with lisinopril and amlodipine. However, he experienced peripheral edema in his lower extremities and significant gingival hyperplasia noted during a dental examination. His primary care physician reduced the amlodipine dose for the edema, but following the dental consultation where gingival hyperplasia was attributed to amlodipine, the patient independently discontinued the medication without medical supervision.

Initial Assessment

At his pre-operative appointment, elevated blood pressure was noted. Subsequent home monitoring revealed consistently elevated readings: 151/90, 160/82, 173/82, 146/90, and 160/100 mmHg. Morning readings prior to medication administration showed right arm 168/106 mmHg and left arm 150/92 mmHg. The patient was taking only lisinopril for blood pressure control at the time of assessment.

The Diagnostic Journey

The temporal relationship between amlodipine discontinuation and blood pressure elevation was established. The patient's blood pressure had been previously well-controlled on dual therapy, suggesting inadequate control with monotherapy. The patient's significant comorbidities including polycythemia vera and obesity were considered as contributing factors to hypertension management complexity.

Final Diagnosis

Uncontrolled essential hypertension secondary to medication non-compliance, with amlodipine-induced gingival hyperplasia and peripheral edema as contributing factors to treatment discontinuation.

Treatment Plan

Immediate blood pressure optimization was recommended prior to elective surgery. Cardiology consultation was suggested for comprehensive hypertension management and alternative antihypertensive regimen selection. Consideration of alternative calcium channel blockers or other antihypertensive classes to replace amlodipine while maintaining adequate blood pressure control.

Outcome and Follow-up

Surgery postponement was recommended pending blood pressure stabilization. Anesthesiology consultation indicated that surgery could potentially proceed with current blood pressure readings depending on individual anesthesiologist assessment and perioperative risk stratification, though optimal control would be preferred for elective procedures. Close follow-up with primary care and cardiology was planned for medication adjustment and long-term hypertension management.