高血压英文课件CardiovascularDiseaseinAmbulatory

Ian Smith,MD,FRCAEditor,Journal of One-day Surgery,Senior Lecturer in AnaesthesiaUniversity Hospital of North StaffordshireStoke-on-TrentCardiovascular Cardiovascular Disease in Ambulatory Disease in Ambulatory SurgerySurgery.Ian Smith,MD,FRCACardiovascuRisk AssessmentRisk Assessment“Despite sophisticated technologies,history and physical examination remain the key elements of preoperative risk assessment”Chassot,et al.Br J Anaesth 89:747,2002.Risk Assessment“Despite sophisCardiac Risk IndexCardiac Risk IndexCoronary artery disease:MI within 6 moMI 6 moAngina:on mild exerciseat minimal exertionPulmonary oedema:within 1 weekeverCritical aortic stenosisArrhythmias:any other than SR or PAC5 PVCsPoor general medical statusAge 70 yearsEmergency surgery105102010520555510Risk factorPointsDetsky,et al.J Gen Int Med 1:211,1986.Cardiac Risk IndexCoronary artClassification of Cardiac RiskClassification of Cardiac RiskMajor risk factors:MI,CABG or stenting 3 morevascularisation 3 mo(asymptomatic,no treatment)Chassot,et al.Br J Anaesth 89:747,2002Intermediate risk factors:MI 6 weeks,6 weeks,6 yearsangina on moderate or strenuous effortprevious perioperative ischaemiasilent ischaemiaventricular arrhythmiadiabetesage(physiological)70family history CADuncontrolled hypertensionhigh cholesterolsmokingabnormal ECGMinor risk factors predict coronary artery disease but not perioperative risk.Classification of Cardiac RiskTooTooComplicated?Complicated?.TooComplicated?.4 Factors4 FactorsSevere anginaPrevious MIHeart failureHypertension.4 FactorsSevere angina.Hypertension:What we KnowHypertension:What we KnowMost important risk factor for:cerebrovascular diseasecoronary heart diseasein general populationMacMahon,et al.Lancet 335:765,1990Control of elevated BP:significantly lowers CVSmorbidity and mortalityCollins,et al.Lancet 335:827,1990.Hypertension:What we KnowMostHypertension&Surgery:Hypertension&Surgery:What we Dont KnowWhat we Dont KnowIs hypertension as an independent risk factor?“plagued by much uncertainty”Does delaying reduce perioperative risk?“unclear”Risk of isolated systolic hypertension?“uncertain”Confirming diagnosis:multiple vs single BP reading?“not yet assessed”Casadei&Abuzeid Journal of Hypertension 23:19,2005.Hypertension&Surgery:What w.Recent PracticeRecent PracticeCancellation at preassessment clinichypertension:57%of medical reasons,by doctorMcIntyre,et al.Journal of Clinical Governance 9:59,2001Orthopaedic surgeryhypertension 16.2%of medical cancellationsWildner,et al.Health Trends 23:115,1991.Recent PracticeCancellation atDeferring Surgery:EvidenceDeferring Surgery:Evidence3 patient groupsuntreated hypertensivetreated hypertensivenormotensiveLabile BP and ischaemiain un-treated and poorly-treated hypertensives“no cause for concern”in othersPrys-Roberts,et al.Br J Anaesth 43:122,1971.Deferring Surgery:Evidence3 pDefinitions Have ChangedDefinitions Have ChangedNormal blood pressure now:120129/8084120/80 is optimalJoint National Committee on prevention,detection,evaluation and treatment of high blood pressure Arch Intern Med 157:2413,1997.Definitions Have ChangedNormalDeferring Surgery:EvidenceDeferring Surgery:EvidenceNormotensive130 11/73 7(high normal)Treated hypertensive174 21/89 12(stage 2 or worse)Untreated hypertensive204 25/102 5(severe hypertension)Prys-Roberts,et al.Br J Anaesth 43:122,1971.Deferring Surgery:EvidenceNor.More Recent EvidenceMore Recent EvidenceMeta-analysis of 30 publications 1978200112,995 patientsRisk of perioperative CVS complicationsin hypertensive patients is 1.35 that in normotensives“clinically insignificant”(unless end-organ damage is clinically-evident)Howell,et al.Br J Anaesth 92:570,2004.More Recent EvidenceMeta-analyAmbulatory Surgery Evidence?Ambulatory Surgery Evidence?7.7%hypertensive patients had CVS“event”Odds ratio 2.47Chung,et al.Br J Anaesth 83:262,1999BUT76%of events“hypertension”9%of events“arrhythmia”No major events.Ambulatory Surgery Evidence?7.RecommendationsRecommendationsStage 1&2 hypertension(180/110 mmHg)“not an independent risk factor for perioperative CVS complications”American Heart Association/American College of CardiologyHowell,et al.Br J Anaesth 92:570,2004Stage 3 hypertension(180/110 mmHg)“should be controlled before surgery”American Heart Association/American College of Cardiologylimited evidenceHowell,et al.Br J Anaesth 92:570,2004.RecommendationsStage 1&2 hypManaging Severe HypertensionManaging Severe HypertensionControlhow?how fast?how long?Deferringhow long?outcome?Perioperative management?.Managing Severe HypertensionCoTreating Severe HypertensionTreating Severe HypertensionSedation will not reduce CVS riskRapid treatment may also increase riskIf deferredfor how long?little evidence that outcome is improvedNeed to consider risks&benefits of surgerycancer versus non-urgent.Treating Severe HypertensionSeRecommendationsRecommendationsPreassessmenteliminate white coat effectconfirm diagnosisrefer for treatment(for long-term benefit)if surgery can waitDay of surgerytry to avoid this scenario!proceed(carefully)if 180/110,or surgery urgentrefer later,if needed.RecommendationsPreassessment.4 Factors4 FactorsSevere anginaPrevious MIHeart failureHypertension.4 FactorsSevere angina.Angina GradingAngina Grading0No angina1Angina on strenuous exertion2Angina causing slight limitation3Angina causing marked limitation4Angina at restNew York Heart Association.Angina GradingNo anginaNew YorTraditionally delayed for 6 months3 months:no further risk reductionunless complicated byarrhythmiasventricular dysfunctioncontinued therapy for symptomsPrevious MIPrevious MIChassot,et al.Br J Anaesth 89:747,2002.Traditionally delayed for 6 moRevascularisation ProceduresRevascularisation ProceduresCABG,angioplasty&stentsReduce risk of CVS eventshigh-risk for 6 weeksdelay surgery 3 monthsrisk increases after 6 yearsAbsence of symptomsGood functional activityChassot,et al.Br J Anaesth 89:747,2002.Revascularisation ProceduresCAHeart FailureHeart FailureDyspnoea at rest or on effortusually worse lying downEnd stage ofcoronary artery diseasehypertensionvalvular heart diseasecardiomyopathy.Heart FailureDyspnoea at rest Can We Make It Even Simpler?Can We Make It Even Simpler?.Can We Make It Even Simpler?.Functional LimitationFunctional LimitationExercise tolerance“major determinant of perioperative risk”Chassot,et al.Br J Anaesth 89:747,2002 Estimated in“Metabolic Equivalents”(METs)Ischaemia 7 METs without ischaemiaLow riskWeiner,et al.Am J Coll Cardiol 3:772,1984.Functional LimitationExercise METs?METs?10 METsstrenuous sport.METs?4 METs.Climbing StairsClimbing Stairs.Climbing Stairs.Climbing StairsClimbing StairsInability to climb 2 flights of stairs89%probability of cardiopulmonary complicationsGirish,et al.Chest 120:1147,2001.Climbing StairsInability to clCardiovascular Risk AssessmentCardiovascular Risk Assessment“Can you climb 2 flights of stairs?”.Cardiovascular Risk AssessmentOptimisationOptimisationConfirm diagnosisEstablish limitationOptimal therapy.OptimisationConfirm diagnosis.Cardiovascular MedicationCardiovascular MedicationContinue-blockersContinue antihypertensives“continuationthroughout the perioperative period is critical”Howell,et al.Br J Anaesth 92:570,2004.Cardiovascular MedicationContiACE Inhibitors?ACE Inhibitors?Greater hypotension at inductionrecommend stoppingBertrand,et al.Anesth Analg 92:26,2001Comfere,et al.Anesth Analg 100:636,2005Hypotension mildComfere,et al.Anesth Analg 100:636,2005Benefits:cardioprotection,renal function,sympathetic responsesrecommend continuingPigott,et al.Br J Anaesth 83:715,2000.ACE Inhibitors?Greater hypotenACE Inhibitors?ACE Inhibitors?Insufficient evidence to stopContinue like other CVS drugsSimplifies instructions.ACE Inhibitors?Insufficient evCardiovascular AssessmentCardiovascular AssessmentSymptoms:angina,SOBSeverity and functional limitationStability of controlCurrent status?optimal.Cardiovascular AssessmentSymptNot For Ambulatory Surgery.Not For Ambulatory Surgery.Angina on minimal exertion or at restMI or revascularisation in past 3 monthsSymptoms after MI or revascularisationUnable to climb 2 flights of stairsexclude respiratory of locomotor causesSignificant cardiovascular limitation of activity.Not For Ambulatory Surgery.A.