cardiovascular disease in ambulatory surgery课件

Ian Smith, MD, FRCA Editor, Journal of One-day Surgery, Senior Lecturer in Anaesthesia University Hospital of North Staffordshire Stoke-on-Trent Cardiovascular Disease in Ambulatory Surgery Risk 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 Cardiac Risk Index Coronary artery disease:MI within 6 mo MI 6 mo Angina:on mild exercise at minimal exertion Pulmonary oedema:within 1 week ever Critical aortic stenosis Arrhythmias:any other than SR or PAC 5 PVCs Poor general medical status Age 70 years Emergency surgery 10 5 10 20 10 5 20 5 5 5 5 10 Risk factorPoints Detsky, et al. J Gen Int Med 1: 211, 1986 Classification of Cardiac Risk Major risk factors: MI, CABG or stenting 3 mo revascularisation 3 mo (asymptomatic, no treatment) Chassot, et al. Br J Anaesth 89: 747, 2002 Intermediate risk factors: MI 6 weeks, 6 weeks, 6 years angina on moderate or strenuous effort previous perioperative ischaemia silent ischaemia ventricular arrhythmia diabetes age (physiological) 70 family history CAD uncontrolled hypertension high cholesterol smoking abnormal ECG Minor risk factors predict coronary artery disease but not perioperative risk Too Complicated? 4 Factors Severe angina Previous MI Heart failure Hypertension Hypertension: What we Know Most important risk factor for: cerebrovascular disease coronary heart disease in general population MacMahon, et al. Lancet 335: 765, 1990 Control of elevated BP: significantly lowers CVS morbidity and mortality Collins, et al. Lancet 335: 827, 1990 Hypertension & Surgery: What we Dont Know Is 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 Recent Practice Cancellation at preassessment clinic hypertension: 57% of medical reasons, by doctor McIntyre, et al. Journal of Clinical Governance 9: 59, 2001 Orthopaedic surgery hypertension 16.2% of medical cancellations Wildner, et al. Health Trends 23: 115, 1991 Deferring Surgery: Evidence 3 patient groups untreated hypertensive treated hypertensive normotensive Labile BP and ischaemia in un-treated and poorly-treated hypertensives “no cause for concern” in others Prys-Roberts, et al. Br J Anaesth 43: 122, 1971 Definitions Have Changed Normal blood pressure now: 120129 / 8084 3 months:no further risk reduction unless complicated by arrhythmias ventricular dysfunction continued therapy for symptoms Previous MI Chassot, et al. Br J Anaesth 89: 747, 2002 Revascularisation Procedures CABG, angioplasty & stents Reduce risk of CVS events high-risk for 6 weeks delay surgery 3 months risk increases after 6 years Absence of symptoms Good functional activity Chassot, et al. Br J Anaesth 89: 747, 2002 Heart Failure Dyspnoea at rest or on effort usually worse lying down End stage of coronary artery disease hypertension valvular heart disease cardiomyopathy Can We Make It Even Simpler? Functional Limitation Exercise 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 risk Weiner, et al. Am J Coll Cardiol 3: 772, 1984 METs? 10 METs strenuous sport Climbing Stairs Climbing Stairs Inability to climb 2 flights of stairs 89% probability of cardiopulmonary complications Girish, et al. Chest 120: 1147, 2001 Cardiovascular Risk Assessment “Can you climb 2 flights of stairs?” Optimisation Confirm diagnosis Establish limitation Optimal therapy Cardiovascular Medication Continue -blockers Continue antihypertensives “continuationthroug hout the perioperative period is critical” Howell, et al. Br J Anaesth 92: 570, 2004 ACE Inhibitors? Greater hypotension at induction recommend stopping Bertrand, et al. Anesth Analg 92: 26, 2001 Comfere, et al. Anesth Analg 100: 636, 2005 Hypotension mild Comfere, et al. Anesth Analg 100: 636, 2005 Benefits: cardioprotection, renal function, sympathetic responses recommend continuing Pigott, et al. Br J Anaesth 83: 715, 2000 ACE Inhibitors? Insufficient evidence to stop Continue like other CVS drugs Simplifies instructions Cardiovascular Assessment Symptoms:angina, SOB Severity and functional limitation Stability of control Current status ? optimal Not For Ambulatory Surgery. Angi