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of hypertension
Costas Tsioufis
Assistant Professor of Cardiology
1st Department of Cardiology, University of Athens
Athens, Greece
CV risk at the peri-operative period
The magnitude of the problem in the Europe
7 million major surgical procedures annually
By the year 2020, the annually conducted procedures will be
increased by >50% and the elderly population by 25%
12% of the women and 18% of men have some degree of CVD in the
age group 75+,
Cardiac
Sympathetic
Output Sodium
Activation
Retention
stress
BP RESPONSE DURING ANESTHESIA
During the induction of anesthesia, sympathetic activation can cause the BP to
rise by 20 - 30 mmHg and the HR to increase by 15 - 20 bpm in normotensive
individuals. These responses may be more pronounced in patients with
untreated hypertension
Pain
Hypercapnia
Agitation
Hypoxemia
Hypervolemia
Male, 64 years old, smoker, dislipidemic and hypertensive with a history of
paroxysmal atrial fibrillation admitted for elective prostatectomy. In the
preoperative evaluation:
HR : 85bpm, clinic BP : 160/85mmHg
No cardiac murmurs, no peripheral edema
Asymptomatic for cardiac symptoms (no angina)
Basic lab tests: within normal values
Recent echo: no LVH, EF=60%, Mild dilatation of LA
Under daily treatment with atorvostatin 20mg , metoprolol 50 mg, aspirin 100 mg and a
fixed combination of irbesartan/HCT 300/12.5mg
Pre-operative evaluation of hypertensive patient
Questions to be answered
1.Type Of Surgery
•Low Risk
•Intermediate Risk
•High Risk
2.Setting of surgery
•Emergent
•Urgent
•Elective
3.Co-Morbidities
Type of surgery and estimated 30–day
cardiac events rates (cardiac death and MI)
Surgical risk estimate (modified from Boersma et al.)
Low-risk <1% Intermediate-risk 1-5% High-risk >5%
Breast Abdominal Aorticand major
Dental Carotid vascular surgery
Endocrine Peripheral arterial angioplasty Peripheral
Drowsiness,
Transdermal 0.1-0.3mg once Abrupt withdrawal†; 0.3mg/24-hour
2-3 days 7 days dizziness; local skin C
clonidine weekly elderly patch, $10
erythema; dry mouth
History
Physical examination
Laboratory evaluation
ECG
History
Family history for atherosclerotic CV disease
Clinical history
Abdominal palpation
Walk a block or 2 on level ground at 2 to Do heavy work around the house like
mph (3.2 to 4.8 kph) scrubbing floors or lifting or moving heavy
furniture?
Do light work around the house like Participate in moderate recreational activities
dusting or washing dishes? like golf, bowling, dancing, doubles tennis,
or throwing a baseball or football?
4 METs
Participate in strenuous sports like swimming,
Greater than singles tennis, skiing?
football, basketball or
10 METs
Electrocardiogram
Should be part of all routine assessment of subjects with
high BP in order to detect LVH, patterns of “strain”,
ischaemia and arrhythmias.
ESH GDLs2007
aClass of recommendation
bLevel of evidence
LV=left ventricular
Preoperative b-blocker
Increase in mortality
withdrawal
Pre-operative evaluation of a hypertensive patient
Treatment should be initiated optimally between 30 days and at least 1 week before
surgery. Target: heart rate 60-70 beats/min. Systolic blood pressure >100mmHg. Use
β1-selective β-blockers without ISA and with a long half-live eg bisoprolol
Recommendations on ACE inhibitor use
Aspirin
Meta-analysis: 41 Studies, 49 590 Patients
Yes
Step 3 Low risk surgery (Class I, LOE B)
Proceed with
planned surgery
No
Step 5 No or unknown
Monitor BP at home