Ian Smith, MD, FRCAEditor, 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 factor,Points,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 120 / 80 is optimalJoint National Committee on prevention, detection, evaluation and treatment of high blood pressure Arch Intern Med 157: 2413, 1997,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,Meta-analysis of 30 publications 19782001 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?,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,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,Control how? how fast? how long? Deferring how long? outcome? Perioperative management?,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,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,Severe angina Previous MI Heart failure Hypertension,Angina Grading,No angina Angina on strenuous exertion Angina causing slight limitation Angina causing marked limitation Angina at rest,New York Heart Association,Traditionally delayed for 6 months 3 months: no further risk reduction unless complicated by arrhythmias ventricular dysfunction continued therapy for symptoms,