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Categorisation of the stages of hypertension.

Categorisation of the stages of hypertension.

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This guideline aims to ensure that patients admitted to hospital for elective surgery are known to have blood pressures below 160 mmHg systolic and 100 mmHg diastolic in primary care. The objective for primary care is to fulfil this criterion before referral to secondary care for elective surgery. The objective for secondary care is to avoid spurio...

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... association of hypertension with cardiovascu- lar disease is established, but there is no clear evidence that patients with stage 1 or 2 hypertension (Table 1) without evidence of target organ damage have increased peri-operative cardiovascular risk [14]. Patients with stage 3 or 4 hypertension, who are more likely to have target organ damage, have not been sub- jected to rigorous randomised controlled trials of peri- operative interventions. ...

Citations

... Whilst there is little evidence supporting the delay of elective surgery for class I or II hypertension patients 47,52 , the extremes of blood pressure are predictive of poorer postsurgical outcomes 47 . In a multi-disciplinary setting, patients being considered for bariatric surgery can be assessed by a bariatric physician who can initiate or optimise treatment as well as assess for cardiovascular risk factors. ...
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    Modifiable risk factors such as diabetes, hyperlipidaemia, hypertension, obstructive sleep apnoea (OSA), chronic kidney disease (CKD), chronic steroid use and smoking, have been shown in observational studies to negatively affect surgical outcomes. The purpose of this study is to identify and determine the effect of modifiable risk factors on post‐operative bariatric surgery leak, as pre‐operative risk modification has been shown to reduce the impact on complications. Electronic literature searches of MEDLINE, PUBMED, OVID and Cochrane Library databases were performed, including a manual reference check, over the period of 2010 and 2020. 620 articles were screened according to the PRISMA protocol. Twenty articles were included in the meta‐analysis of risk factors. Significant risk factors and the associated effect sizes include: 1. smoking with an overall OR of 1.31 [1.06, 1.61] and an OR of 1.72 [1.44, 2.05] in sleeve gastrectomy patient cohorts; 2. diabetes with an overall OR of 1.23 [1.08, 1.39] and an OR of 1.33 [1.02, 1.73] in Roux‐en‐Y patient cohorts; 3. CKD with an overall OR of 2.41 [1.62, 3.59] and 4. steroid use with an overall OR of 1.57 [1.22, 2.02].Non‐significant risk factors include hypertension with an OR of 0.85, 1.83, OSA with an OR of 1.08 [0.83, 1.39] and hyperlipidaemia with an OR of 0.80 [0.61, 1.04]. Combined sleeve gastrectomy and Roux‐en‐Y patient cohorts with hyperlipidaemia have shown a protective effect of 0.78 [0.65, 0.94]. Significant risk factors for leak post bariatric surgery are smoking in all patients and particularly sleeve gastrectomy patients, diabetes for all patients and particularly Roux‐en‐Y patients, and CKD and chronic steroid for all patients. Hyperlipidaemia in two combined patient cohorts (sleeve gastrectomy and Roux‐en‐Y) appears to have a weak protective effect. This article is protected by copyright. All rights reserved.
    ... Even though there are several international reference guidelines that account for the importance of management of perioperative BP [6][7][8], at present there are no universally accepted preoperative BP thresholds, as BP targets need to consider patient baseline BP, surgery type, and risk of short-term complications [9]. Furthermore, there is a clear gap in the knowledge of short-and long-term implications of acute hypo-and hypertensive perioperative episodes. ...
    Article
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    Study objective Our goal is to review the outcomes of acute hypertensive/hypotensive episodes from articles published in the past 10 years that assessed the short- and long-term impact of acute hypertensive/hypotensive episodes in the perioperative setting. Methods We conducted a systematic peer review based upon PROSPERO and Cochrane Handbook protocols. The following study characteristics were collected: study type, author, year, population, sample size, their definition of acute hypertension, hypotension or other measures, and outcomes (probabilities, odds ratio, hazard ratio, and relative risk) and the p-values; and they were classified according to the type of surgery (cardiac and non-cardiac). Results A total of 3,680 articles were identified, and 66 articles fulfilled the criteria for data extraction. For the perioperative setting, the number of articles varies by outcome: 20 mortality, 16 renal outcomes, 6 stroke, 7 delirium and 34 other outcomes. Hypotension was reported to be associated with mortality (OR 1.02–20.826) as well as changes from the patient’s baseline blood pressure (BP) (OR 1.02–1.36); hypotension also had a role in the development of acute kidney injury (AKI) (OR 1.03–14.11). Postsurgical delirium was found in relation with BP lability (OR 1.018–1.038) and intra- and postsurgical hypotension (OR 1.05–1.22), and hypertension (OR 1.44–2.34). Increased OR (37.67) of intracranial hemorrhage was associated to postsurgical systolic BP >130 mmHg. There was a wide range of additional diverse outcomes related to hypo-, hypertension and BP lability. Conclusions The perioperative management of BP influences short- and long-term effects of surgical procedures in cardiac and non-cardiac interventions; these findings support the burden of BP fluctuations in this setting.
    ... Why is an optimal pre-anesthesia blood pressure important? Preoperative hypertension can cause perioperative hemodynamic changes associated with perioperative morbidity and mortality, such as intraoperative hypotension and tachycardia [24,25]. It has been claimed that hypertensive patients may have greater cardiovascular lability and exaggerated hemodynamic stress response, particularly at the induction of anesthesia, due to increased catecholamine levels and increased sensitivity of peripheral vessels to catecholamines [26]. ...
    Article
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    Background: Blood pressure fluctuations appear more significant in patients with poorly controlled hypertension and are known to be associated with adverse perioperative morbidity. In the present study, we aimed to determine the effects of antihypertensive drug treatment strategies on preanesthetic operating room blood pressure measurements. Methods: A total of 717 patients participated in our study; 383 patients who were normotensive based on baseline measurements and not under antihypertensive therapy were excluded from the analysis. The remaining 334 patients were divided into six groups according to the antihypertensive drug treatment. These six groups were examined in terms of preoperative baseline and pre-anesthesia blood pressure measurements. Results: As a result of the study, it was observed that 24% of patients had high blood pressure precluding surgery, and patients using renin-angiotensin-aldosterone system inhibitors (RAASI) had higher pre-anesthesia systolic blood pressure than patients using other antihypertensive drugs. Patients who received beta-blockers were also observed to have the lowest pre-anesthesia systolic blood pressure, diastolic blood pressure, and mean blood pressure, compared to others. Conclusions: Recently, whether RAASI should be continued preoperatively remains controversial. Our study shows that RAASI cannot provide optimal pre-anesthesia blood pressure and lead to an increase in the number of postponed surgeries, probably due to withdrawal of medication before the operation. Therefore, the preoperative discontinuation of RAASI should be reevaluated in future studies.
    ... In an additional experiment, we used a collection of hypertension management guidelines from different countries, including the USA, Canada, Brasil, the UK and Ireland [70][71][72][73][74][75][76][77]. The corpus was created by searching PubMed for "practice guideline" as "publication type" and "hypertension" and as the "major MeSh" index. ...
    ... We selected eight of them from different medical bodies, where the full text of the guidelines was available. This corpus consists of the following eight documents: CHEP2007 [70], the 2007 Canadian Hypertension Education Program; AHA & ASH & PCNA [71], joint statement of the American Heart Association, American Society Of Hypertension, and Preventive Cardiovascular Nurses Association; BGAH [72], the Brazilian Guideline of Arterial Hypertension; CFP [73], the 2013 Canadian screening recommendations; AAGBI & BHS [74], the 2016 joint British ...
    Article
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    Using natural language processing tools, we investigate the semantic differences in medical guidelines for three decision problems: breast cancer screening, lower back pain and hypertension management. The recommendation differences may cause undue variability in patient treatments and outcomes. Therefore, having a better understanding of their causes can contribute to a discussion on possible remedies. We show that these differences in recommendations are highly correlated with the knowledge brought to the problem by different medical societies, as reflected in the conceptual vocabularies used by the different groups of authors. While this article is a case study using three sets of guidelines, the proposed methodology is broadly applicable. Technically, our method combines word embeddings and a novel graph-based similarity model for comparing collections of documents. For our main case study, we use the CDC summaries of the recommendations (very short documents) and full (long) texts of guidelines represented as bags of concepts. For the other case studies, we compare the full text of guidelines with their abstracts and tables, summarizing the differences between recommendations. The proposed approach is evaluated using different language models and different distance measures. In all the experiments, the results are highly statistically significant. We discuss the significance of the results, their possible extensions, and connections to other domains of knowledge. We conclude that automated methods, although not perfect, can be applicable to conceptual comparisons of different medical guidelines and can enable their analysis at scale.
    ... (MRI) or Diffusion tensor imaging (DTI))confirming nerve root compression. 4. Good general condition: blood pressure after intervention < 160 mmHg systolic and < 100 mmHg diastolic [10]; intraoperative blood glucose levels < 10 mmol/l (The Society for Ambulatory Anesthesia) [11]. Cardiopulmonary function, assessed by the anesthesiologist, is able to tolerate general anesthesia. ...
    Article
    Full-text available
    Background: Bilateral decompression via unilateral approach (BDUA) is an effective surgical approach for treating lumbar degenerative diseases. However, no studies of prognosis, especially the recovery of the soft tissue, have reported using BDUA in an elderly population. The aims of these research were to investigate the early efficacy of the bilateral decompression via unilateral approach versus conventional approach transforaminal lumbar interbody fusion (TLIF) for the treatment of lumbar degenerative disc disease in the patients over 65 years of age, especially in the perioperative factors and the recovery of the soft tissue. Methods: The clinical data from 61 aging patients with lumbar degenerative disease who received surgical treatment were retrospectively analyzed. 31 cases who received the lumbar interbody fusion surgery with bilateral decompression via unilateral approach (BDUA) were compared with 30 cases who received conventional approach transforaminal lumbar interbody fusion. The radiographic parameters were measured using X-ray including lumbar lordosis angle and fusion rate. Japanese Orthopedic Association (JOA), Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) scores were used to evaluate the clinical outcomes at different time points. Fatty degeneration ratio and area of muscle/vertebral body were used to detect recovery of soft tissue. Results: The BDUA approach group was found to have significantly less intraoperative blood loss(p < 0.05) and postoperative drainage(p < 0.05) compared to conventional approach transforaminal lumbar interbody fusion group. Symptoms of spinal canal stenosis and nerve compression were significantly relieved postoperatively, as compared with the preoperative state. However, the opposite side had a lower rate of fatty degeneration (9.42 ± 3.17%) comparing to decompression side (11.68 ± 3.08%) (P < 0.05) six months after surgery in the BDUA group. While there were no significant differences (P > 0.05) in two sides of conventional transforaminal lumbar interbody fusion approach group six months after surgery. Conclusions: Bilateral decompression via unilateral approach (BDUA) is able to reduce the intraoperative and postoperative body fluid loss in the elderly. The opposite side of decompression in BDUA shows less fatty degeneration in 6 months, which indicates better recovery of the soft tissue of the aging patients.
    ... The anaesthetist needs to be meticulous in the choice of medications for GA in the management of the hypertensive surgical patient to avoid upsurge in blood pressure. Hypertensive surges greater than 20% from the baseline are associated with 10 adverse outcomes. Care is needed in the choice of drugs for premedication, induction and maintenance of anaesthesia. ...
    Article
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    Background: Hypertension is a medical condition that may co-exist with any surgical disease. Hypertension is defined as a sustained increase in blood pressure (BP) >140/90 mm Hg in a patient not taking antihypertensive drugs. It has been estimated that the overall prevalence of hypertension in Nigeria is 28.9%. Hypertension becomes a challenge to the anaesthetist when the hypertensive patient presents for an emergency operation. Methodology: This study was a retrospective audit review of anaesthetic charts, case notes and operation records of adult patients that were operated at the accident and emergency (A&E) theatre of a tertiary hospital in the North-West zone of Nigeria over a 6 months period during 2014. Patient's age, sex, type of surgery and anaesthetic technique were collated. Data obtained were expressed as numbers and percentages. Results: A total of 182 adult patients had emergency surgery. Females were 95(52.2%). General surgery had the highest number (38.5%) of patients followed by Obstetrics with 32.4%. Gynaecological surgery had the lowest number of patients (5.5%). Forty (22%) of patients operated during the period had high blood pressure (>140/90mmHg). Twelve of the hypertensive patients (30%) had urological operations followed by general surgical procedures with 11 patients (27.5%). Four patients (10%) had gynaecological surgery. General anaesthesia (GA) was administered in 80% of the cases while the remaining 8 patients had spinal anaesthesia. Conclusion: Twenty two percent of study patients were hypertensive and most of them had urological or general surgical procedures. GA was the preferred technique of anaesthesia during the review period. Keywords: Anaesthesia, Emergency, Hypertension, Surgical patient
    ... This was done in accordance with recommendations in the Joint Guidelines from the Association of Anaesthetists of Great Britain and Ireland and the British Hypertension Society. [9] The present substudy was approved by the ). All patients provided written informed consent and the Revised Standards for Quality Improvement Reporting (SQUIRE) were followed. ...
    Article
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    Background: The prevalence of hypertension in adults in South Africa (SA) is 35%. Hypertension is the most important modifiable risk factor for cardiovascular (CV) and chronic kidney disease (CKD) in sub-Saharan Africa. However, 49% of people are unaware of their blood pressure status. Screening for hypertension prior to surgery provides a unique opportunity to diagnose and treat affected individuals. Furthermore, assessing overall CV risk identifies patients at highest risk for complications, and improves the utilisation of scarce resources. Objectives: To evaluate the CV risk profile of hypertensive patients in the adult population of the Western Cape Province presenting for elective non-cardiac, non-obstetric surgery. Methods: This report documents the CV risk profile of patients recruited to the HASS-2 study (Hypertension and Surgery Study 2), which was undertaken in seven Western Cape hospitals. Patients were screened for hypertension and pharmacological treatment was initiated or adjusted in patients with stages 1 and 2 disease. Stage 3 patients were referred to a physician. In the present substudy, patients with stages 1 and 2 hypertension were assessed for associated CV risk factors, the presence of target organ damage, and documented CV or kidney disease; they received an overall risk stratification according to the 2018 European Society of Cardiology and the European Society of Hypertension Guidelines. Results: Sixty-one patients with stage 1 and 12 with stage 2 hypertension were analysed. Established CV disease was present in 13.7% of the study population, and CKD (eGFR <60 mL/min) in 10.8%. Seventy-one percent of the study group had a raised body mass index, and 55.9% underlying metabolic syndrome. Prediabetes and diabetes were present in 16.1% and 14.5%, respectively. According to the 2018 European guidelines, 34.7% were at moderate, 33.3% at high and 16.7% at very high risk for a CV event in the following 10 years. Conclusions: The perioperative period is a critical time during which surgeons, nurses and anaesthetists can influence patients' CV risk of adverse events. This involves appropriate screening, education and treatment. In this study population, nearly 9 out of 10 elective surgical patients with stage 1 or 2 hypertension had CV risk factors placing them at moderate to very high risk. The simultaneous assessment of these additional CV risk parameters, in addition to diagnosis and management of hypertension, may further decrease the health and financial burden in resource-limited facilities in SA, and improve CV outcomes.
    ... This was conducted over a 5-day period in each institution, between January and March 2019. Eligible participants were all adult in-patients admitted on the day before surgery, undergoing elective surgery with blood pressure (BP) above the normal range, 13,14 which included newly diagnosed hypertensives and those with poorly controlled hypertension. Exclusion criteria were cardiac, obstetric, and day case surgery, as well as radiological or ophthalmic procedures under local anesthesia, and patients with BPs within normal ranges, including those with well-controlled hypertension. ...
    ... The BP measurements were conducted using the automated office BP (AOBP) method, in accordance with recommendations in the Joint Guidelines from the Association of Anesthesiologists of Great Britain and Ireland, the British Hypertension Society, and the Canadian Hypertension Guideline. 14,15 The measurements were performed the day before surgery, to mitigate the effect of anxiety on BP. The automated device used was a Dinamap Carescape Monitor (Woodley Equipment Company Ltd, Lancashire, UK), which has been validated. ...
    Article
    Full-text available
    Background: Hypertension is a common risk factor for cardiovascular morbidity and mortality, with a high prevalence in patients presenting for elective surgery. In limited resource environments, patients have poor access to primary care physicians, limiting the efficacy of lifestyle modification for the management of hypertension. In these circumstances, the perioperative period presents a unique opportunity for diagnosis and initiation and/or modification of pharmacotherapy of hypertension. Anesthesiologists are ideally placed to lead this aspect of perioperative medicine. The study objective was for anesthesiologists to identify patients at the preoperative visit with previously undiagnosed or poorly controlled chronic hypertension and follow a simple management algorithm. Methods: In collaboration with expert physicians, we designed and implemented an algorithm for the diagnosis and management of chronic hypertension. This was a multicenter, cross-sectional quality improvement project in 7 hospitals in the Western Cape, South Africa. On the day before scheduled elective surgery, adult in-patients had 2 sets of blood pressure (BP) readings taken, one by nurses and the other by anesthesiologists, using a noninvasive automated BP device. These were averaged on an electronic database, to diagnose hypertension. Patients with normal BP or well-controlled hypertension required no further management. Those with borderline BP received educational pamphlets. Patients with stage 1 or 2 hypertension were managed with medication according to the algorithm, starting 1 day postoperatively, and provided with educational pamphlets. Patients with stage 3 disease had their surgery postponed and were referred to a physician. The primary outcome was adherence by the anesthesiologist to the algorithm in the diagnosis and management of hypertension. An 80% adherence rate was considered successful implementation. The secondary outcome was the adherence to the algorithm at discharge. Results: Two hundred ninety-eight patients were screened for hypertension. One hundred six patients were eligible for the quality improvement project. Thirty-seven (34.9%) had borderline BP readings, 43 (40.6%) had stage 1, 22 (20.8%) stage 2, and 4 (3.8%) stage 3 hypertension, respectively. The adherence rate by the anesthesiologist in initiating treatment according to the algorithm was 89 of 106 (84.0%; 95% confidence interval [CI, 77.0-91.0). There was full adherence to the algorithm in 59 of 106 (55.5%; 95% CI, 46.2-65.1) at the time of discharge from hospital. Conclusions: Anesthesiologists successfully implemented a quality improvement project for diagnosis and management of hypertension in the perioperative period. This has the potential to reduce the public health burden of hypertension in limited resource environments. Successful ongoing prescription and follow-up requires cooperation within a multidisciplinary team.
    ... blood pressure after intervention < 160 mmHg systolic and <100 mmHg diastolic [11]; intraoperative blood glucose levels <10 mmol/l(The Society for Ambulatory Anesthesia) [12]. Cardiopulmonary function, assessed by the anesthesiologist, is able to tolerate general anesthesia. ...
    Preprint
    Full-text available
    Background: Bilateral decompression via unilateral approach(BDUA) is an effective surgical approach for treating lumbar degenerative diseases.However, no studies of prognosis, especially the recovery of the soft tissue, have reported using BDUA in an elderly population.The aims of these research were to investigate the early efficacy of the bilateral decompression via unilateral approach versus conventional approach transforaminal lumbar interbody fusion(TLIF)for the treatment of lumbar degenerative disc disease in the patients over 65 years of age, especially in the perioperative factors and the recovery of the soft tissue. Methods: The clinical data from 61 aging patients with lumbar degenerative disease who received surgical treatment were retrospectively analyzed. 31 cases who received the lumbar interbody fusion surgery with bilateral decompression via unilateral approach (BDUA) were compared with 30 cases who received conventional approach transforaminal lumbar interbody fusion. The radiographic parameters were measured using X-ray including lumbar lordosis angle and fusion rate. Japanese Orthopedic Association (JOA), Visual Analogue Scale (VAS) and Oswestry Disability Index(ODI)scores were used to evaluate the clinical outcomes at different time points. Fatty degeneration ratio and area of muscle/vertebral body were used to detect recovery of soft tissue. Results: The BDUA approach group was found to have significantly less intraoperative blood loss(p<0.05) and postoperative drainage(p<0.05) compared to conventional approach transforaminal lumbar interbody fusion group. Symptoms of spinal canal stenosis and nerve compression were significantly relieved postoperatively, as compared with the preoperative state. However, the opposite side had a lower rate of fatty degeneration (9.42±3.17%) comparing to decompression side (11.68±3.08%) (P<0.05) six months after surgery in the BDUA group. While there were no significant differences (P>0.05) in two sides of conventional transforaminal lumbar interbody fusion approach group six months after surgery. Conclusions: Bilateral decompression via unilateral approach (BDUA) is able to reduce the intraoperative and postoperative body fluid loss in the elderly. The opposite side of decompression in BDUA shows less fatty degeneration in 6 months, which indicates better recovery of the soft tissue of the aging patients.
    ... 'The measurement of adult BP and management of hypertension before elective surgery' [12] In order to assess the impact of the guidelines on cancellation rates related to pre-operative hypertension, we performed prospective, regional multicentre service evaluations before and after the publication of the guidelines. To the best of our knowledge, the effectiveness of any Association of Anaesthetists peri-operative guidelines has not been previously assessed on such a broad scale. ...
    Article
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    Patients with uncontrolled hypertension are at increased risk of complications during general anaesthesia but the number of patients whose surgery is delayed or cancelled due to hypertension remains unknown. Prospective, regional multicentre service evaluations were performed on consecutive patients undergoing elective surgery before and after the publication of new guidelines from the Association of Anaesthetists and the British Hypertensive Society. The aim was to quantify the number of operations cancelled due to hypertension alone and to assess impact of the guidelines on cancellation rates. In October 2013 (before the publication of the guidelines), 1.37% (95%CI 0.69-2.11%) of patients listed for elective surgery were cancelled solely due to raised blood pressure. This reduced significantly to 0.54% (95%CI 0.20-0.92%, p < 0.001) in 2018. There was a significant reduction in inappropriate cancellations for stage 1 or 2 hypertension from 2013 to 2018 (72 vs. 14, respectively, p < 0.001) in keeping with the recommendations in the guidelines. Furthermore, the number of patients being referred back to primary care for the management of hypertension reduced from 2013 to 2018 (85 vs. 30, respectively, p < 0.001). Our data suggest achievement of three major outcomes: reduced surgical cancellations due to hypertension alone; improved detection of significant hypertension before elective surgery; and reduced referral back to primary care from hospital for hypertension management. To the best of our knowledge, this is the first time the successful implementation of guidelines from the Association of Anaesthetists has been assessed on such a broad scale. Our data indicate that these guidelines have been effectively implemented in both primary and secondary care, which is likely to have made a positive psychosocial, physical and economic impact on patients and the NHS.