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Journal Reading

2016/06/28
Presenter: Int
Supervisor: VS

The patient with hypertension


undergoing surgery
Curr Opin Anaesthesiol. 29(3):397-402, June 2016
Lapage KG, Wouters PF.

Outline
INTRODUCTION
IMPORTANCE OF PREOPERATIVE HYPERTENSION
CARDIOVASCULAR PATHOPHYSIOLOGY
PULSE PRESSURE AND ISOLATED SYSTOLIC HYPERTENSION
LEFT VENTRICULAR HYPERTROPHY AND DIASTOLIC DYSFUNCTI
ON IN HYPERTENSIVE PATIENTS

INTRAOPERATIVE BLOOD PRESSURE MANAGEMENT


MONITORING TOOLS
3

INTRODUCTION

Hypertension
The majority of patients with hypertensiv
e disease have additional risk factors for c
ardiovascular and renal events, which mo
dify this relationship.
Independent relationship between BP an
d
incidence of stroke, myocardial infarction, su
dden death, heart failure, peripheral artery di
sease, and renal disease.
Sundstrom J, et al. Lancet,
2014

Epidemiology
2000 : 972 million patients (26.4%)
2025 : 1.56 billion patients (29.2%)
An alarmingly 60% increase in just 25 yea
Kearney, P.M et al. Lancet,
rs.
2005

In Taiwan male 25% and female


Cheng18%.
H-M et al. Pulse, 2015
7

Recent guidelines focus on

BP and Total cardiovascular risk


as the primary determinant for selecting a
specific antihypertensive drug treatment.
Sundstrom J, et al. Lancet,
2014

Dyslipidemia, old age, DM, male,


Smoking, recent CVD, high BMI
8

BP control based on evidence


Strong evidence support long term tight B
P control can prevent cardiovascular even
ts.
Does not apply to the perioperative perio
d.
Little evidence that affects postoperative outc
ome.
9

Hemodynamic Management
Base hemodynamic control on understan
ding of the pathophysiology of the diseas
e.
With new monitoring techniques like
Near-infrared spectroscopy:
Provide better guidance in optimizing BP contr
ol for individual patients.
10

IMPORTANCE OF
PREOPERATIVE HYPERTENSIO
N
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IMPORTANCE OF
PREOPERATIVE HYPERTENSION
The perioperative risk of chronic hypertension i
s determined primarily by the presence of longterm consequences.
CAD, stroke, heart failure, and renal failure
All known to affect perioperative morbidity a
nd mortality.
Fleisher L, et al. Circulation,
2014

12

Authors suggestions-1
Clinicians may consider not deferring nonca
rdiac surgery in patients with
Grade 1 and 2 hypertension.
Patients with a new diagnosis of hypertensio
n should be screened for end-organ damage
and cardiovascular risk factors.
A preoperative EKG and serum Crea level is r
equired.
13

Authors suggestions-2
B-type natriuretic peptide
Correlate with cardiac inflammatory processe
s and remodeling in asymptomatic hypertens
ive patients.
Preoperative B-type natriuretic peptide could
be a useful adjunct for risk stratification.
Currently there is insufficient evidence for ro
utine use as a screening test in hypertensive
patients.
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Delaying surgery
Valid reasons for delaying surgery
BP of grade 3
Discovery of end-organ damage that has not
previously been evaluated or treated
Suspicion of secondary hypertension without
properly documented cause

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CARDIOVASCULAR PATHOPHYS
IOLOGY
16

CARDIOVASCULAR PATHOPHYSIOLOG
Y
Protection of capillaries from continuous expos
ure to high pressures
Increased myogenic tone, arteriolar vasocons
triction
Functional and structural capillary rarefaction
.

structural capillary rarefaction


Occur through cell apoptosis
Induced by low shear stress conditions in the
non-perfused microvessels.
17

18

Eutrophic inward remodeling


Occurs in capillaries
Persistent increase in BP In
duces structural remodelin
g.
Creates a chronic elevation
of vascular resistance.
Cause exaggerated respons
e to vasopressors typically i
n hypertensive patients.
19

Arterial stiffening
Chronic hypertension:
Loss of compliance

Function of artery:
buffer stroke volume a
nd pressure
preserve continuous o
rgan perfusion during
diastole.
20

Windkessel effect
The transformation of cyclic cardiac strok
e volumes into a smooth continuous forw
ard flow.
In chronic hypertension
Less efficient
Arterial pressure waves typically show an incr
eased amplitude with larger pulse pressures
Increased difference between SBP and DBP.
21

Hypertensiv
Healthy
e

22

Continuous increase in
cardiac afterload
Increased workload
induces LV
hypertrophy.
Gradual loss of LV
compliance and
diastolic function.

Decreased DBPs
Impaired myocardial
perfusion
Hypertrophic
myocardium more
likely to suffer
myocardial ischemia.

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Isolated Systolic
Hypertension
and
Pulse Pressure
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Isolated Systolic Hypertension and Pulse


Pressure
Loss of
elastin in
conduit
Isolatedarteries
systolic
hypertension

Aging

Arterial
stiffening

Low or normal DBP


/
Increased pulse
pressure

Attempts to decrease SBP toward normal r


anges may cause diastolic hypotension and
organ hypoperfusion.

Pulse Pressure
In cardiac surgery, high preoperative pulse pressure
s have been associated with a three-fold increase in
perioperative mortality, an increased incidence of re
nal impairment, and with reduced long-term survival
.

*
Risk Index for Perioperative Renal
Dysfunction/ Failure Critical
Dependence on Pulse Pressure
Hypertension

Measure for Arterial StiffnessPulse Wave Velocity(PWV)


A stiffer vessel will conduct the pulse wave faster t
han a more distensible and compliant vessel.

An increase in aortic
PWV by 1 m/s
increase of 15% in
CVD mortality.
Carotid-femoral PWV
(cfPWV)
Brachial-ankle PWV
(baPWV)

Left Ventricular
Hypertrophy(LVH)
and
Diastolic Dysfunction

Diastolic Dysfunction
Hypertens
ion

LV
H

Diastolic
dysfunction

Asymptomatic diastolic dysfunction has been associ


ated with higher 30-day and long-term cardiovascul
ar morbidity in patients undergoing vascular surger
y.

*Prognostic Implications of Asymptomatic Left Ventricular Dysfunction in Patients

Diastolic Dysfunction

Poor Tolerance to Hypovolemia


VS.
Increased Risk for Fluid Overload
Echocardiography-based Doppler interrogation of tra
nsmitral flow and mitral annular velocity (E/E)has bec
ome the standard technique to assess diastolic functi
on.

Monitoring Tools
Pulse Contour Analysis estimating
compliance, not arterial stiffening

Near-infrared spectroscopy(NIRS)

noninvasive neuromonitoring, hemodynamic


status(venous oxygen concentrations, regional
tissue, organ perfusion)

Microcirculation pathophysiological c
hanges in resistance vessels and precapill
ary arterioles, and capillary rarefaction

Intraoperative Blood Pressure Manageme


nt

Table 2. Recommendations for the perioperative


management of patients with hypertensive disease (opinion
based)
Preoperative

Intraoperative Postoperative

SAP180mmHg,
DAP110mmHg

MAP not
lower than
2530%
of awake

Resume antihypertensive
drugs upon oral intake or
substitute i.v.

ECG, serum
creatinine,
electrolytes
(diuretics) search
for target organ
damage (heart,
brain, kidney)

Attenuate
sympathetic
response to
laryngoscopy
(or laryngeal
mask)

Measure blood pressure every


515 min first hour then every
30 min until 3 h postoperative

Antihypertensive
drugs; Continue
DOS(day of surgery):
b-blockers,

Consider use
of
noninvasive
cardiac

Treat postoperative
hypertension to MAP>100 and
<130mmHg and HR 50bpm ;
Metoprolol: repeat 25mg

Conclusion
Hypertensive disease causes pathophysiolo
gical changes to the cardiovascular system
and is associated with target organ damage
that affects perioperative outcome.
An individualized and pathophysiology-base
d approach to control intraoperative BP ma
y be the best option to guide hypertensive p
atients through the perioperative period.

THE END