EditorWe are most grateful for the opportunity to reply to Dr Palmer's letter. He raises two points. The first is to suggest that the correction of minor degrees of hypertension before surgery is more appropriate than the use of invasive monitoring and high-dependency care in these cases. For admission blood pressures between 120/80 mm Hg and 180/110 mm Hg we were unable to find any evidence of increased perioperative risk. We accept that it is biologically plausible that such blood pressures may confer a small increase in risk. However, this effect is beyond the resolving power of currently available studies, and major cardiovascular risk factors such as heart failure and known ischaemic heart disease are more important indicators of perioperative risk. We have tried to produce guidelines that are pragmatic and clinically useful and, on this basis, we felt unable to recommend deferring surgery to control a risk whose existence we cannot demonstrate.
For admission blood pressures persistently above 180/110 mm Hg, the position is less clear. While there are no data to support an increased incidence of adverse events in this group of patients, the work of Prys-Roberts and colleagues does suggest that patients with very high blood pressures display a greater fall in blood pressure at induction of anaesthesia and are more prone to intraoperative myocardial ischaemia.
5 It is for patients with blood pressure elevated to this level that we suggest that anaesthesia and surgery should be deferred where possible to allow the blood pressure to be controlled and, where this is not possible, the use of invasive monitoring and high-dependency care may be appropriate.
We would emphasize that we seek to offer guidelines to aid the clinician, not edicts to ordain patient care. There will certainly be circumstances in which persistently elevated admission blood pressure may, of itself, be a cause for concern. Refractory hypertension in a young patient, suggestive of secondary hypertension, is one such circumstance.
Dr Palmer's second point, on the role of the anaesthetist and surgeon in the primary and secondary prevention of cardiovascular disease, is very well taken. Smoking, obesity and alcohol abuse are difficult problems to tackle but, as physicians concerned with the well being of the whole patient, they certainly fall within our remit.
S. Howell1, J. Sear2 and P. Foëx2 
