Professional Documents
Culture Documents
2016/06/28
Presenter: Int
Supervisor: VS
Outline
INTRODUCTION
IMPORTANCE OF PREOPERATIVE HYPERTENSION
CARDIOVASCULAR PATHOPHYSIOLOGY
PULSE PRESSURE AND ISOLATED SYSTOLIC HYPERTENSION
LEFT VENTRICULAR HYPERTROPHY AND DIASTOLIC DYSFUNCTI
ON IN HYPERTENSIVE PATIENTS
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
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
11
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.
14
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
15
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
.
18
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.
23
Isolated Systolic
Hypertension
and
Pulse Pressure
24
Aging
Arterial
stiffening
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
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
Diastolic Dysfunction
Monitoring Tools
Pulse Contour Analysis estimating
compliance, not arterial stiffening
Near-infrared spectroscopy(NIRS)
Microcirculation pathophysiological c
hanges in resistance vessels and precapill
ary arterioles, and capillary rarefaction
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)
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