ian smith, md, frca editor, journal of one-day surgery, senior lecturer in anaesthesia university...
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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
Cardiovascular Disease in Ambulatory
Surgery
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Risk 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
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Cardiac Risk IndexCardiac Risk Index
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
Risk factor Points
Detsky, et al. — J Gen Int Med 1: 211, 1986
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Classification of Cardiac RiskClassification 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)
Chassot, et al. — Br J Anaesth 89: 747, 2002
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
family history CADuncontrolled hypertensionhigh cholesterolsmokingabnormal ECG
Minor risk factors predict coronary artery disease but not perioperative risk
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TooComplicated?
TooComplicated?
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4 Factors4 Factors
•Severe angina
•Previous MI
•Heart failure
•Hypertension
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Hypertension: What we KnowHypertension: 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
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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
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Recent PracticeRecent 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
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Deferring Surgery: EvidenceDeferring 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
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Definitions Have ChangedDefinitions 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
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Deferring Surgery: EvidenceDeferring 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
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More Recent EvidenceMore 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
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Ambulatory Surgery Evidence?Ambulatory Surgery Evidence?
• 7.7% hypertensive patients had CVS “event”
• Odds ratio 2.47
Chung, et al. — Br J Anaesth 83: 262, 1999
•BUT• 76% of events “hypertension”
• 9% of events “arrhythmia”
• No major events
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RecommendationsRecommendations
• 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
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Managing Severe HypertensionManaging Severe Hypertension
•Control– how?
– how fast?
– how long?
•Deferring– how long?
– outcome?
•Perioperative management?
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Treating Severe HypertensionTreating 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
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RecommendationsRecommendations
• 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
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4 Factors4 Factors
•Severe angina
•Previous MI
•Heart failure
•Hypertension
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Angina GradingAngina Grading
0No angina
1Angina on strenuous exertion
2Angina causing slight limitation
3Angina causing marked limitation
4Angina at rest
New York Heart Association
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• 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
Previous MIPrevious MI
Chassot, et al. — Br J Anaesth 89: 747, 2002
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Revascularisation ProceduresRevascularisation 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
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Heart FailureHeart Failure
• Dyspnoea at rest or on effort– usually worse lying down
• End stage of– coronary artery disease
– hypertension
– valvular heart disease
– cardiomyopathy
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Can We Make It Even Simpler?Can We Make It Even Simpler?
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Functional LimitationFunctional 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
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METs?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
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Climbing StairsClimbing Stairs
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Climbing StairsClimbing Stairs
• Inability to climb 2 flights of stairs– 89% probability of cardiopulmonary complications
– Girish, et al. — Chest 120: 1147, 2001
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Cardiovascular Risk AssessmentCardiovascular Risk Assessment
• “Can you climb 2 flights of stairs?”
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OptimisationOptimisation
• Confirm diagnosis
• Establish limitation
• Optimal therapy
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Cardiovascular MedicationCardiovascular Medication
• Continue -blockers
• Continue antihypertensives– “continuation…throughout the perioperative period is
critical”– Howell, et al. —
Br J Anaesth 92: 570, 2004
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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
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ACE Inhibitors?ACE Inhibitors?
• Insufficient evidence to stop
• Continue like other CVS drugs
• Simplifies instructions
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Cardiovascular AssessmentCardiovascular Assessment
• Symptoms: angina, SOB
• Severity and functional limitation
• Stability of control
• Current status– ? optimal
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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
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