高血压英文课件CardiovascularDiseaseinAmbulatory-2

1、Ian Smith, MD, FRCAEditor, Journal of One-day Surgery,Senior Lecturer in AnaesthesiaUniversity Hospital of North StaffordshireStoke-on-TrentCardiovascular Disease in Ambulatory Surgery.Ian Smith, MD, FRCACardiovascuRisk Assessment“Despite sophisticated technologies, history and physical examination

2、remain the key elements of preoperative risk assessment”Chassot, et al. Br J Anaesth 89: 747, 2002.Risk Assessment“Despite sophisCardiac Risk IndexCoronary artery disease:MI within 6 moMI 6 moAngina:on mild exerciseat minimal exertionPulmonary oedema:within 1 weekeverCritical aortic stenosisArrhythm

3、ias: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 RiskMajor risk factors:MI, CABG or stenting 3 morevascularisation 3 mo(asympt

4、omatic, 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 hypertensionhi

5、gh cholesterolsmokingabnormal ECGMinor risk factors predict coronary artery disease but not perioperative risk.Classification of Cardiac RiskTooComplicated?.TooComplicated?.4 FactorsSevere anginaPrevious MIHeart failureHypertension.4 FactorsSevere angina.Hypertension: What we KnowMost important risk

6、 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:What we Dont KnowIs hyp

7、ertension 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.Hyperte

8、nsion & Surgery:What w.Recent 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 Practic

9、eCancellation atDeferring 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 pDefiniti

10、ons 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: EvidenceNormotensive130 11 / 73 7(high normal)

11、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 EvidenceMeta-analysis of 30 publications 1978200112,995 patientsRisk of perioperative CVS complicati

12、onsin 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?7.7% hypertensive patients had CVS “event”Odds ratio 2.47Chung, et al.

13、 Br J Anaesth 83: 262, 1999BUT76% of events “hypertension”9% of events “arrhythmia”No major events.Ambulatory Surgery Evidence?7.RecommendationsStage 1 & 2 hypertension (180 / 110 mmHg)“not an independent risk factor for perioperative CVS complications”American Heart Association / American College o

14、f 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 Hypertensi

15、onControlhow?how fast?how long?Deferringhow long?outcome?Perioperative management?.Managing Severe HypertensionCoTreating Severe HypertensionSedation will not reduce CVS riskRapid treatment may also increase riskIf deferredfor how long?little evidence that outcome is improvedNeed to consider risks &

16、 benefits of surgerycancer versus non-urgent.Treating Severe HypertensionSeRecommendationsPreassessmenteliminate 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 urgen

17、trefer later, if needed.RecommendationsPreassessment.4 FactorsSevere anginaPrevious MIHeart failureHypertension.4 FactorsSevere angina.Angina GradingNo anginaAngina on strenuous exertionAngina causing slight limitationAngina causing marked limitationAngina at restNew York Heart Association.Angina Gr

18、adingNo anginaNew YorTraditionally delayed for 6 months3 months:no further risk reductionunless complicated byarrhythmiasventricular dysfunctioncontinued therapy for symptomsPrevious MIChassot, et al. Br J Anaesth 89: 747, 2002.Traditionally delayed for 6 moRevascularisation ProceduresCABG, angiopla

19、sty & 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 FailureDyspnoea at rest or on effortusually worse lying downEnd stage

20、ofcoronary artery diseasehypertensionvalvular heart diseasecardiomyopathy.Heart FailureDyspnoea at rest Can We Make It Even Simpler?.Can We Make It Even Simpler?.Functional LimitationExercise tolerance“major determinant of perioperative risk”Chassot, et al. Br J Anaesth 89: 747, 2002 Estimated in “M

21、etabolic Equivalents” (METs)Ischaemia 7 METs without ischaemiaLow riskWeiner, et al. Am J Coll Cardiol 3: 772, 1984.Functional LimitationExercise METs?10 METsstrenuous sport.METs?4 METs.Climbing Stairs.Climbing Stairs.Climbing StairsInability to climb 2 flights of stairs89% probability of cardiopulm

22、onary complicationsGirish, et al. Chest 120: 1147, 2001.Climbing StairsInability to clCardiovascular Risk Assessment“Can you climb 2 flights of stairs?” .Cardiovascular Risk AssessmentOptimisationConfirm diagnosisEstablish limitationOptimal therapy.OptimisationConfirm diagnosis.Cardiovascular Medica

23、tionContinue -blockersContinue antihypertensives“continuationthroughout the perioperative period is critical”Howell, et al. Br J Anaesth 92: 570, 2004.Cardiovascular MedicationContiACE Inhibitors?Greater hypotension at inductionrecommend stoppingBertrand, et al. Anesth Analg 92: 26, 2001Comfere, et al. Anesth Analg 100: 636, 2005Hypotension mildCom