cardiovascular disease in ambulatory surgery l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Cardiovascular Disease in Ambulatory Surgery PowerPoint Presentation
Download Presentation
Cardiovascular Disease in Ambulatory Surgery

Loading in 2 Seconds...

play fullscreen
1 / 38

Cardiovascular Disease in Ambulatory Surgery - PowerPoint PPT Presentation


  • 158 Views
  • Uploaded on

Cardiovascular Disease in Ambulatory Surgery. Ian Smith , MD, FRCA Editor, Journal of One-day Surgery , Senior Lecturer in Anaesthesia University Hospital of North Staffordshire Stoke-on-Trent. Risk Assessment.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Cardiovascular Disease in Ambulatory Surgery' - aldon


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
cardiovascular disease in ambulatory surgery

Cardiovascular Disease in Ambulatory Surgery

Ian Smith, MD, FRCA

Editor, Journal of One-day Surgery,

Senior Lecturer in Anaesthesia

University Hospital of North Staffordshire

Stoke-on-Trent

risk assessment
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
Cardiac Risk Index

Risk factor

Points

Coronary artery disease: MI within 6 moMI > 6 mo

Angina: on mild exerciseat minimal exertion

Pulmonary oedema: within 1 weekever

Critical aortic stenosis

Arrhythmias: any other than SR or PAC>5 PVCs

Poor general medical status

Age >70 years

Emergency surgery

105

1020

105

20

55

5

5

10

Detsky, et al. — J Gen Int Med 1: 211, 1986

classification of cardiac risk
Classification of Cardiac Risk

Major risk factors:MI, CABG or stenting <6 weeksangina on minimal exertion or at restresidual ischaemia following MIischaemia with CCF or malignant rhythm

Minor risk factors:MI >3 morevascularisation >3 mo(asymptomatic, no treatment)

family history CADuncontrolled hypertensionhigh cholesterolsmokingabnormal ECG

Intermediate risk factors:MI >6 weeks, <3 morevascularisation >6 weeks, <3 mo, or >6 yearsangina on moderate or strenuous effortprevious perioperative ischaemiasilent ischaemiaventricular arrhythmiadiabetesage (physiological) >70

Minor risk factors predict coronary artery disease but not perioperative risk

Chassot, et al. — Br J Anaesth 89: 747, 2002

slide6

4 Factors

  • Severe angina
  • Previous MI
  • Heart failure
  • Hypertension
hypertension what we know
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 CVSmorbidity and mortality
      • Collins, et al. — Lancet 335: 827, 1990
hypertension surgery what we don t know
Hypertension & Surgery:What we Don’t 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
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
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
Definitions Have Changed
  • Normal blood pressure now:
    • 120–129 / 80–84
    • <120 / 80 is optimal
      • Joint National Committee on prevention, detection, evaluation and treatment of high blood pressure — Arch Intern Med 157: 2413, 1997
deferring surgery evidence13
Deferring Surgery: Evidence
  • Normotensive
    • 130 ± 11 / 73 ± 7 (high normal)
  • Treated hypertensive
    • 174 ± 21 / 89 ± 12 (stage 2 or worse)
  • Untreated hypertensive
    • 204 ± 25 / 102 ± 5 (severe hypertension)
      • Prys-Roberts, et al. — Br J Anaesth 43: 122, 1971
more recent evidence
More Recent Evidence
  • Meta-analysis of 30 publications 1978–2001
  • 12,995 patients
  • Risk of perioperative CVS complications
    • in 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
ambulatory surgery evidence
Ambulatory Surgery Evidence?
  • 7.7% hypertensive patients had CVS “event”
  • Odds ratio 2.47
  • BUT
  • 76% of events “hypertension”
  • 9% of events “arrhythmia”
  • No major events

Chung, et al. — Br J Anaesth 83: 262, 1999

recommendations
Recommendations
  • Stage 1 & 2 hypertension (<180 / 110 mmHg)
    • “not an independent risk factor for perioperative CVS complications”
      • American Heart Association / American College of Cardiology
      • Howell, et al. — Br J Anaesth 92: 570, 2004
  • Stage 3 hypertension (≥180 / 110 mmHg)
    • “should be controlled before surgery”
      • American Heart Association / American College of Cardiology
    • limited evidence
      • Howell, et al. — Br J Anaesth 92: 570, 2004
managing severe hypertension
Managing Severe Hypertension
  • Control
    • how?
    • how fast?
    • how long?
  • Deferring
    • how long?
    • outcome?
  • Perioperative management?
treating severe hypertension
Treating Severe Hypertension
  • Sedation will not reduce CVS risk
  • Rapid treatment may also increase risk
  • If deferred
    • for how long?
    • little evidence that outcome is improved
  • Need to consider risks & benefits of surgery
    • cancer versus non-urgent
recommendations20
Recommendations
  • Preassessment
    • eliminate white coat effect
    • confirm diagnosis
    • refer for treatment (for long-term benefit)
      • if surgery can wait
  • Day of surgery
    • try to avoid this scenario!
    • proceed (carefully) if <180 / 110, or surgery urgent
      • refer later, if needed
4 factors
4 Factors
  • Severe angina
  • Previous MI
  • Heart failure
  • Hypertension
angina grading
Angina Grading
  • No angina
  • Angina on strenuous exertion
  • Angina causing slight limitation
  • Angina causing marked limitation
  • Angina at rest

New York Heart Association

previous mi
Previous MI
  • Traditionally delayed for 6 months
  • <6 weeks: high risk
  • 6 weeks–3 months: intermediate risk
  • >3 months: no further risk reduction
    • unless complicated by
      • arrhythmias
      • ventricular dysfunction
      • continued therapy for symptoms

Chassot, et al. — Br J Anaesth 89: 747, 2002

revascularisation procedures
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
Heart Failure
  • Dyspnoea at rest or on effort
    • usually worse lying down
  • End stage of
    • coronary artery disease
    • hypertension
    • valvular heart disease
    • cardiomyopathy
functional limitation
Functional Limitation
  • Exercise tolerance
    • “major determinant of perioperative risk”
      • Chassot, et al. — Br J Anaesth 89: 747, 2002
  • Estimated in “Metabolic Equivalents” (METs)
  • Ischaemia <5 METs High risk
  • >7 METs without ischaemia Low risk
      • Weiner, et al. — Am J Coll Cardiol 3: 772, 1984
slide28
METs?
  • <4 METs
    • light housework
    • walk around house
    • walk 1–2 blocks on flat
  • 5–9 METs
    • climb flight of stairs
    • play golf or dance
  • >10 METs
    • strenuous sport
climbing stairs30
Climbing Stairs
  • Inability to climb 2 flights of stairs
    • 89% probability of cardiopulmonary complications
      • Girish, et al. — Chest 120: 1147, 2001
cardiovascular risk assessment
Cardiovascular Risk Assessment
  • “Can you climb 2 flights of stairs?”
optimisation
Optimisation
  • Confirm diagnosis
  • Establish limitation
  • Optimal therapy
cardiovascular medication
Cardiovascular Medication
  • Continue -blockers
  • Continue antihypertensives
    • “continuation…throughout the perioperative period is critical”
      • Howell, et al. — Br J Anaesth 92: 570, 2004
ace inhibitors
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 inhibitors35
ACE Inhibitors?
  • Insufficient evidence to stop
  • Continue like other CVS drugs
  • Simplifies instructions
cardiovascular assessment
Cardiovascular Assessment
  • Symptoms: angina, SOB
  • Severity and functional limitation
  • Stability of control
  • Current status
    • ? optimal
not for ambulatory surgery
Not For Ambulatory Surgery...
  • Angina on minimal exertion or at rest
  • MI or revascularisation in past 3 months
  • Symptoms after MI or revascularisation
  • Unable to climb 2 flights of stairs
    • exclude respiratory of locomotor causes
  • Significant cardiovascular limitation of activity