Cardiovascular Disease in Ambulatory Surgery课件.ppt

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 “Despite sophisticated technologies, history and physical examination remain the key elements of preoperative risk assessment” Cardiac Risk Index Classification of Cardiac Risk TooComplicated? 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 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” 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: 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: 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 Me