RESUMO
Arterial pressure monitoring and management are mainstays of haemodynamic therapy in patients having surgery. This article presents updated consensus statements and recommendations on perioperative arterial pressure management developed during the 11th POQI PeriOperative Quality Initiative (POQI) consensus conference held in London, UK, on June 4-6, 2023, which included a diverse group of international experts. Based on a modified Delphi approach, we recommend keeping intraoperative mean arterial pressure ≥60 mm Hg in at-risk patients. We further recommend increasing mean arterial pressure targets when venous or compartment pressures are elevated and treating hypotension based on presumed underlying causes. When intraoperative hypertension is treated, we recommend doing so carefully to avoid hypotension. Clinicians should consider continuous intraoperative arterial pressure monitoring as it can help reduce the severity and duration of hypotension compared to intermittent arterial pressure monitoring. Postoperative hypotension is often unrecognised and might be more important than intraoperative hypotension because it is often prolonged and untreated. Future research should focus on identifying patient-specific and organ-specific hypotension harm thresholds and optimal treatment strategies for intraoperative hypotension including choice of vasopressors. Research is also needed to guide monitoring and management strategies for recognising, preventing, and treating postoperative hypotension.
Assuntos
Pressão Arterial , Consenso , Hipotensão , Assistência Perioperatória , Humanos , Pressão Arterial/fisiologia , Determinação da Pressão Arterial/métodos , Determinação da Pressão Arterial/normas , Hipotensão/diagnóstico , Hipotensão/terapia , Hipotensão/prevenção & controle , Complicações Intraoperatórias/prevenção & controle , Complicações Intraoperatórias/terapia , Complicações Intraoperatórias/diagnóstico , Monitorização Intraoperatória/métodos , Monitorização Intraoperatória/normas , Assistência Perioperatória/métodos , Assistência Perioperatória/normas , Complicações Pós-Operatórias/prevenção & controle , Complicações Pós-Operatórias/diagnósticoRESUMO
PURPOSE OF REVIEW: Elevated blood pressure (BP) and hypertension in childhood convey risk for hypertension and cardiovascular events in adulthood. Early recognition of abnormal BPs is key to preventing or lessening this risk. However, the process for making the diagnosis of hypertension is complex, and overall adherence to the 2017 American Academy of Pediatrics Clinical Practice Guidelines (CPG) is poor. We will review obstacles to adherence to the CPG and approaches designed to improve the diagnosis and management of hypertension in children. RECENT FINDINGS: Baseline data from the multi-center quality improvement intervention, "Boosting Primary Care Awareness and Treatment of Hypertension" (BP-CATCH), demonstrate that childhood hypertension remains underdiagnosed. Other studies confirm a lack of compliance with the process outlined in the CPG. The provision of electronic prompts, coaching, and education results in modest improvements. The combination of embedded medical record tools and education seems to offer the most hope for improvement.
Assuntos
Hipertensão , Guias de Prática Clínica como Assunto , Humanos , Hipertensão/diagnóstico , Hipertensão/terapia , Criança , Programas de Rastreamento/métodos , Pressão Sanguínea/fisiologia , Fidelidade a Diretrizes , Determinação da Pressão Arterial/métodos , Determinação da Pressão Arterial/normas , Anti-Hipertensivos/uso terapêuticoRESUMO
Importance: Hypertension is a prevalent condition that affects approximately 45% of the adult US population and is the most commonly diagnosed condition at outpatient office visits. Hypertension is a major contributing risk factor for heart failure, myocardial infarction, stroke, and chronic kidney disease. Objective: To reaffirm its 2015 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of screening for hypertension in adults, the accuracy of office blood pressure measurement for initial screening, and the accuracy of various confirmatory blood pressure measurement methods. Population: Adults 18 years or older without known hypertension. Evidence Assessment: Using a reaffirmation deliberation process, the USPSTF concludes with high certainty that screening for hypertension in adults has substantial net benefit. Recommendation: The USPSTF recommends screening for hypertension in adults 18 years or older with office blood pressure measurement. The USPSTF recommends obtaining blood pressure measurements outside of the clinical setting for diagnostic confirmation before starting treatment. (A recommendation).
Assuntos
Determinação da Pressão Arterial/métodos , Hipertensão/diagnóstico , Programas de Rastreamento/normas , Adolescente , Adulto , Determinação da Pressão Arterial/normas , Monitorização Ambulatorial da Pressão Arterial , Doenças Cardiovasculares/prevenção & controle , HumanosRESUMO
Although antihypertensive medications are effective, inexpensive, and recommended by clinical practice guidelines, a large percentage of older adults with hypertension have uncontrolled blood pressure (BP). Improving BP control in this population may require a better understanding of the specific challenges to BP control at older age. In this narrative review, we propose a framework for considering how key steps in BP management occur in the context of aging characterized by heterogeneity in function, multiple co-occurring health conditions, and complex personal and environmental factors. We review existing literature related to 4 necessary steps in hypertension control. These steps include the BP measure which can be affected by the technique, device, and setting in which BP is measured. Ensuring proper technique can be challenging in routine care. The plan includes setting BP treatment goals. Lower BP goals may be appropriate for many older adults. However, plans must take into account the generalizability of existing evidence, as well as patient and family's health goals. Treatment includes the management strategy, the expected benefits, and potential risks of treatment. Treatment intensification is commonly needed and can contribute to polypharmacy in older adults. Lastly, monitor refers to the need for ongoing follow-up to support a patient's ability to sustain BP control over time. Sustained BP control has been shown to be associated with a lower rate of cardiovascular disease and multimorbidity progression. Implementation of current guidelines in populations of older adults may be improved when specific challenges to BP measurement, planning, treating, and monitoring are addressed.
Assuntos
Hipertensão/prevenção & controle , Idoso , Anti-Hipertensivos/uso terapêutico , Determinação da Pressão Arterial/normas , Humanos , Hipertensão/epidemiologia , Multimorbidade , Melhoria de Qualidade/organização & administraçãoRESUMO
BACKGROUND: In most patients having noncardiac surgery, blood pressure is measured with the oscillometric upper arm cuff method. Although the method is noninvasive and practical, it is known to overestimate intraarterial pressure in hypotension and to underestimate it in hypertension. A high-fidelity upper arm cuff incorporating a hydraulic sensor pad was recently developed. The aim of the present study was to investigate whether noninvasive blood pressure measurements with the new high-fidelity cuff correspond to invasive measurements with a femoral artery catheter, especially at low blood pressure. METHODS: Simultaneous measurements of blood pressure recorded from a femoral arterial catheter and from the high-fidelity upper arm cuff were compared in 110 patients having major abdominal surgery or neurosurgery. RESULTS: 550 pairs of blood pressure measurements (5 pairs per patient) were considered for analysis. For mean arterial pressure measurements, the average bias was 0 mmHg, and the precision was 3 mmHg. The Pearson correlation coefficient was 0.96 (P < 0.0001; 95% CI, 0.96 to 0.97), and the percentage error was 9%. Error grid analysis showed that the proportions of mean arterial pressure measurements done with the high-fidelity cuff method were 98.4% in zone A (no risk), 1.6% in zone B (low risk) and 0% in zones C, D, and E (moderate, significant, and dangerous risk, respectively). The high-fidelity cuff method detected mean arterial pressure values less than 65 mmHg with a sensitivity of 84% (95% CI, 74 to 92%) and a specificity of 97% (95% CI, 95% to 98%). To detect changes in mean arterial pressure of more than 5 mmHg, the concordance rate between the two methods was 99.7%. Comparable accuracy and precision were observed for systolic and diastolic blood pressure measurements. CONCLUSIONS: The new high-fidelity upper arm cuff method met the current international standards in terms of accuracy and precision. It was also very accurate to track changes in blood pressure and reliably detect severe hypotension during noncardiac surgery.
Assuntos
Pressão Arterial/fisiologia , Determinação da Pressão Arterial/métodos , Determinação da Pressão Arterial/normas , Monitorização Intraoperatória/métodos , Monitorização Intraoperatória/normas , Adulto , Idoso , Idoso de 80 Anos ou mais , Determinação da Pressão Arterial/instrumentação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/instrumentação , Oscilometria/instrumentação , Oscilometria/métodos , Oscilometria/normas , Estudos Prospectivos , Adulto JovemRESUMO
The goal of the University of California Davis Health Blood Pressure (BP) Quality Improvement Initiative was to improve the diagnosis, management and control of high BP. Patients aged 18-85 years were included in the initiative. Lean A3 problem solving was used to implement the following evidence-based interventions based on stakeholder interviews, value stream mapping and the Centers for Disease Control and Prevention's Million Hearts Initiative: staff training on accurate BP measurement, visual cues and reminders for BP screening, virtual case-based videoconferences, standardised clinical management algorithm, academic detailing visits, clinical decision support tools, access to pharmacists for medication comanagement, clinician workflow modification, patient education and access to home BP monitors. Following implementation of interventions, accurate screening of BP increased from 14% to 87% and BP control increased from 62% to 75%. Strategies that contributed the most to improvements were using a team-based approach, adjusting clinic workflow and frequent communication of results to staff.
Assuntos
Determinação da Pressão Arterial/normas , Programas de Rastreamento/normas , Centros Médicos Acadêmicos/organização & administração , Centros Médicos Acadêmicos/estatística & dados numéricos , Centros Médicos Acadêmicos/tendências , Adolescente , Adulto , Idoso , Determinação da Pressão Arterial/tendências , California , Feminino , Humanos , Hipertensão/diagnóstico , Hipertensão/fisiopatologia , Masculino , Programas de Rastreamento/métodos , Programas de Rastreamento/tendências , Pessoa de Meia-Idade , Melhoria de QualidadeRESUMO
BACKGROUND: Central blood pressure (BP) assessed noninvasively considerably underestimates true invasively measured aortic BP in chronic kidney disease (CKD) patients. The difference between the estimated and the true aortic BP increases with decreasing estimated glomerular filtration rates (eGFR). The present study investigated whether aortic calcification affects noninvasive estimates of central BP. METHODS: Twenty-four patients with CKD stage 4-5 undergoing coronary angiography and an aortic computed tomography scan were included (63% males, age [mean ± SD ] 53 ± 11 years, and eGFR 9 ± 5 mL/min/1.73 m2). Invasive aortic BP was measured through the angiography catheter, while non-invasive central BP was obtained using radial artery tonometry with a SphygmoCor® device. The Agatston calcium score (CS) in the aorta was quantified on CT scans using the CS on CT scans. RESULTS: The invasive aortic systolic BP (SBP) was 152 ± 23 mm Hg, while the estimated central SBP was 133 ± 20 mm Hg. Ten patients had a CS of 0 in the aorta, while 14 patients had a CS >0 in the aorta. The estimated central SBP was lower than the invasive aortic SBP in patients with aortic calcification compared to patients without (mean difference 8 mm Hg, 95% CI 0.3-16; p = 0.04). The brachial SBP was lower than the aortic SBP in patients with aortic calcification compared to patients without (mean difference 10 mm Hg, 95% CI 2-19; p = 0.02). CONCLUSION: In patients with advanced CKD the presence of aortic calcification is associated with a higher difference between invasively measured central aortic BP and non-invasive estimates of central BP as compared to patients without calcifications.
Assuntos
Aorta/fisiopatologia , Determinação da Pressão Arterial/métodos , Calcinose , Insuficiência Renal Crônica/fisiopatologia , Adulto , Aorta/patologia , Pressão Arterial , Determinação da Pressão Arterial/normas , Cateterismo , Feminino , Taxa de Filtração Glomerular , Humanos , Masculino , Pessoa de Meia-Idade , Rigidez VascularRESUMO
There is a dearth of information regarding the reliability of non-invasive measures of vascular function taken in a single testing session. This study aimed to determine the test-retest reliability of a test battery of vascular function measures: automated blood pressure (BP), laser Doppler imaging with iontophoresis (LDI), digital volume pulse (DVP), pulse wave velocity (PWV), augmentation index (AIx) measured by pulse wave analysis (PWA) and flow-mediated dilation (FMD) taken within and between sessions. Measures were taken in 21 non-smoking males intra-session and again inter-session (one week apart) to determine repeatability and reproducibility, respectively. There was moderate to excellent repeatability (ICC: 0.53-0.93; CV=2.2-18.1%) and reproducibility (ICC: 0.71-0.96; CV 1.9-14.2%) for BP, DVP stiffness index, PWV, AIx, AIx normalised to heart rate (75 bpm), absolute and percentage FMD. Repeatability of the DVP reflection index was moderate (ICC: 0.64; CV=9.5%) but there was poor reproducibility (ICC: 0.17; CV=15.1%). Moreover, the repeatability and reproducibility of the LDI measures ranged from poor to good (ICC: 0.31-0.84; CV=28.4-36.7%). These data indicated that there was considerable variability in the repeatability and reproducibility of measurements of endothelial function and arterial stiffness taken in a battery of measurements, which needs careful consideration in future research designs.
Assuntos
Determinação da Pressão Arterial/métodos , Determinação da Pressão Arterial/normas , Análise de Onda de Pulso , Adulto , Dilatação , Frequência Cardíaca , Humanos , Iontoforese , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Adulto JovemRESUMO
We evaluated the performance of a new simple formula (NSF) for the screening of hypertension by American Academy of Pediatrics Guidelines 2017 (AAPG2017) in children with overweight/obesity (OW/OB). The performance of the NSF and the modified blood pressure to height ratio (MBPHR3) thresholds against AAPG2017 was evaluated; both methods were also compared to assess the association with concentric left ventricular hypertrophy (cLVH). The study included 3259 OW/OB children (5-13 years). Two centers served as learning sample (LS) (n = 1428), four centers served as validation sample (VS) (n = 1831), and the echocardiographic evaluation was available in 409 children in VS. The NSF was [1.5 × systolic blood pressure (mmHg) + diastolic blood pressure (mmHg)] - [(26 × height (m)] - age (years). A cut-off of the NSF ≥ 193 mmHg showed sensitivity, specificity, positive, and negative predictive values of 0.92, 0.93, 0.83, and 0.97, respectively, versus the standard procedure. Against AAPG2017, the NSF showed higher specificity and positive predictive values than the MBPHR3 thresholds. Among hypertensive children defined by AAPG2017, NSF, or MBPHR3, the odds ratio (95%CI) for cLVH was respectively 1.73 (1.06-2.83), 1.69 (1.05-2.75), and 1.18 (0.75-1.85).Conclusions: The NSF shows a very high performance for the screening of OW/OB children at risk of hypertension and cLVH. What is Known: ⢠The American Academy of Pediatrics released updated guidelines (AAPG 2017) to classify hypertension (HTN) in children. ⢠The process needs categorization of height percentiles and comparison of blood pressure versus gender and age-adjusted values. What is New: ⢠A user-friendly formula built on the AAPG 2017 was validated for the categorization of HTN in children with overweight/obesity. ⢠The formula showed high performance in identifying children with HTN versus the standard procedure (sensitivity 0.92, specificity 0.93) and similar ability in identifying hypertensive children with concentric left ventricular hypertrophy versus the standard procedure (40% and 39% respectively).
Assuntos
Determinação da Pressão Arterial/métodos , Hipertensão/diagnóstico , Programas de Rastreamento/métodos , Obesidade Infantil/complicações , Adolescente , Determinação da Pressão Arterial/normas , Criança , Pré-Escolar , Bases de Dados Factuais , Feminino , Humanos , Hipertensão/etiologia , Masculino , Programas de Rastreamento/normas , Pediatria/normas , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , Sociedades Médicas/normasAssuntos
Anti-Hipertensivos/uso terapêutico , Determinação da Pressão Arterial , Hipertensão , Programas de Rastreamento/métodos , Polissonografia/métodos , Apneia Obstrutiva do Sono , Doenças Assintomáticas/epidemiologia , Determinação da Pressão Arterial/métodos , Determinação da Pressão Arterial/normas , Dissidências e Disputas , Resistência a Medicamentos , Humanos , Hipertensão/diagnóstico , Hipertensão/epidemiologia , Hipertensão/psicologia , Hipertensão/terapia , Avaliação das Necessidades , Apneia Obstrutiva do Sono/diagnóstico , Apneia Obstrutiva do Sono/epidemiologia , Apneia Obstrutiva do Sono/fisiopatologiaRESUMO
PURPOSE OF REVIEW: Hypertension is a leading disease in preoperative clinics; nearly 60% of patients over 60 years have it. Many guidelines have been published for the diagnosis and treatment of hypertension. Last year, the American College of Cardiology/American Heart Association and European Society of Cardiology and European Society of Hypertension made new recommendations for diagnosis and management, with special emphasis on targets, nonpharmacological treatment, and management of the elderly patient, and pharmacological therapy. We will review relevant concordances and differences that are important for the anesthesiologist and perioperative management. RECENT FINDINGS: Adults with stage 1 hypertension have a two-fold increase in cardiovascular disease risk. Tight blood pressure management improves outcome. Discontinuing angiotensin receptor blockers/angiotensin converting enzyme inhibitors is associated with less intraoperative hypotension and probably less morbidity and mortality. SUMMARY: New guidelines could increase the burden of patients with pharmacological treatment that will need surgery and require case by case considerations. The scarcity of information demands trials about blood pressure management and consensus about antihypertensive medications in perioperative period.
Assuntos
Anti-Hipertensivos/administração & dosagem , Hipertensão/complicações , Assistência Perioperatória/normas , Complicações Pós-Operatórias/prevenção & controle , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Pressão Sanguínea/efeitos dos fármacos , Pressão Sanguínea/fisiologia , Determinação da Pressão Arterial/normas , Humanos , Hipertensão/diagnóstico , Hipertensão/tratamento farmacológico , Hipertensão/fisiopatologia , Assistência Perioperatória/métodos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/fisiopatologia , Guias de Prática Clínica como Assunto , Sociedades Médicas/normasRESUMO
Recent guidelines on diagnosis and management of high blood pressure (BP) include substantial changes and several new concepts compared with previous guidelines. These are reviewed and their clinical implications are discussed in this article. The goal is to provide a practical reference to assist clinicians with up-to-date management of patients with high BP. Important issues include new diagnostic thresholds, out-of-office BP monitoring, intensified treatment goals, and a different approach to resistant hypertension. Finally, differences among guidelines, the persistent controversies that have led to them, and their implications for clinical practice are discussed.
Assuntos
Hipertensão/diagnóstico , Hipertensão/terapia , Guias de Prática Clínica como Assunto , American Heart Association , Anti-Hipertensivos/administração & dosagem , Determinação da Pressão Arterial/normas , Monitorização Ambulatorial da Pressão Arterial , Relações Comunidade-Instituição , Combinação de Medicamentos , Humanos , Estilo de Vida , Programas de Rastreamento , Anamnese , Adesão à Medicação , Equipe de Assistência ao Paciente , Potássio na Dieta/administração & dosagem , Pré-Hipertensão/diagnóstico , Sódio na Dieta/administração & dosagem , Telemedicina , Estados UnidosRESUMO
BACKGROUND AND PURPOSE: Blood pressure measurement represents the pressure exerted during heart ejection and filling. There are several ways to measure blood pressure and a valid measure is essential. The purpose of this study was to evaluate the approach to noninvasive blood pressure measurement in children. METHODS: Blood pressure measurements were taken using the automatic Phillips MP30 monitor and compared against Welch Allyn blood pressure cuffs with Medline manual sphygmomanometers. RESULTS: A total of 492 measurements were taken on 82 subjects, and they demonstrated comparability between automatic and manual devices. CONCLUSIONS: Although our study indicated acceptable agreement between automatic and manual blood pressure measurement, it also revealed measurement error remains a concern, with sample size, study protocol, training, and environment all playing a role.
Assuntos
Determinação da Pressão Arterial/instrumentação , Determinação da Pressão Arterial/estatística & dados numéricos , Determinação da Pressão Arterial/normas , Pressão Sanguínea/fisiologia , Erros Médicos/estatística & dados numéricos , Esfigmomanômetros/estatística & dados numéricos , Esfigmomanômetros/normas , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Reprodutibilidade dos TestesRESUMO
BACKGROUND: Kidney tubulointerstitial fibrosis on biopsy is a strong predictor of chronic kidney disease (CKD) progression, and CKD is associated with elevated risk of cardiovascular disease (CVD). Tubular health is poorly quantified by traditional kidney function measures, including estimated glomerular filtration rate (eGFR) and albuminuria. We hypothesized that urinary biomarkers of tubular injury, inflammation, and repair would be associated with higher risk of CVD and mortality in persons with CKD. METHODS: We measured urinary concentrations of interleukin-18 (IL-18), kidney injury molecule-1, neutrophil gelatinase-associated lipocalin, monocyte chemoattractant protein-1, and chitinase-3-like protein-1 (YKL-40) at baseline among 2,377 participants of the Systolic Blood Pressure Intervention Trial who had an eGFR < 60 mL/min/1.73 m2. We used Cox proportional hazards models to evaluate biomarker associations with CVD events and all-cause mortality. RESULTS: At baseline, the mean age of participants was 72 ± 9 years, and eGFR was 48 ± 11 mL/min/1.73 m2. Over a median follow-up of 3.8 years, 305 CVD events (3.6% per year) and 233 all-cause deaths (2.6% per year) occurred. After multivariable adjustment including eGFR, albuminuria, and urinary creatinine, none of the biomarkers showed statistically significant associations with CVD risk. Urinary IL-18 (hazard ratio [HR] per 2-fold higher value, 1.14; 95% CI 1.01-1.29) and YKL-40 (HR per 2-fold higher value, 1.08; 95% CI 1.02-1.14) concentrations were each incrementally associated with higher mortality risk. Associations were similar when stratified by randomized blood pressure arm. CONCLUSIONS: Among hypertensive trial participants with CKD, higher urinary IL-18 and YKL-40 were associated with higher risk of mortality, but not CVD.
Assuntos
Albuminúria/diagnóstico , Doenças Cardiovasculares/epidemiologia , Hipertensão/tratamento farmacológico , Túbulos Renais/patologia , Insuficiência Renal Crônica/mortalidade , Idoso , Idoso de 80 Anos ou mais , Albuminúria/imunologia , Albuminúria/patologia , Albuminúria/urina , Anti-Hipertensivos/administração & dosagem , Biomarcadores/urina , Pressão Sanguínea/efeitos dos fármacos , Pressão Sanguínea/fisiologia , Determinação da Pressão Arterial/normas , Doenças Cardiovasculares/etiologia , Progressão da Doença , Feminino , Fibrose , Taxa de Filtração Glomerular/fisiologia , Humanos , Hipertensão/fisiopatologia , Hipertensão/urina , Túbulos Renais/imunologia , Masculino , Prognóstico , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/imunologia , Insuficiência Renal Crônica/urinaRESUMO
BACKGROUND: Management of chronic kidney disease (CKD) patients includes efforts directed toward modifying traditional cardiovascular risk factors. Such efforts include optimal management of hypertension together with the initiation of statin therapy. METHODS: In this observational study, we determine the modifying effect of statins on the relationship of systolic blood pressure (SBP) goal with mortality and other outcomes in patients with CKD participating in a clinical trial. At baseline, 2,646 CKD patients (estimated glomerular filtration rate < 60 mL/min/1.73 m2) were randomized to an intensive SBP goal < 120 mm Hg or standard SBP goal <140 mm Hg. One thousand two hundred and seventy-three were not on statin, 1,354 were on a statin, and in 19 the use of statin was unknown. The 2 primary outcomes were all-cause mortality and cardiovascular disease (CVD) mortality. RESULTS: The relationships of SBP goal with all-cause mortality (interaction p = 0.009) and cardiovascular (CV) mortality (interaction p = 0.021) were modified by the use of statin after adjusting for age, gender, race, CVD history, smoking, aspirin use, and blood pressure at baseline. In the statin group, targeting SBP to < 120 mm Hg compared to SBP < 140 mm Hg significantly reduced the risk of all-cause mortality (adjusted hazard ratio [aHR] 0.44 [0.28-0.71]; event rates 1.16 vs. 2.5 per 100 patient-years) and CV mortality (aHR 0.29 [0.12-0.74]; event rates 0.28 vs. 0.92 per 100 patient-years) after a median follow-up of 3.26 years. In the non-statin group, the risk of all-cause mortality (aHR 1.07 [0.69-1.66]; event rates 2.01 vs. 1.94 per 100 patient-years) and CV mortality (aHR 1.42 [0.56-3.59]; event rates 0.52 vs. 0.41 per 100 patient-years) were not significantly different in both SBP goal arms. CONCLUSION: The combination of statin therapy and intensive SBP management leads to improved survival in hypertensive patients with CKD.
Assuntos
Anti-Hipertensivos/administração & dosagem , Pressão Sanguínea/efeitos dos fármacos , Inibidores de Hidroximetilglutaril-CoA Redutases/administração & dosagem , Hipertensão/tratamento farmacológico , Insuficiência Renal Crônica/complicações , Idoso , Determinação da Pressão Arterial/normas , Causas de Morte , Quimioterapia Combinada/métodos , Feminino , Seguimentos , Taxa de Filtração Glomerular/fisiologia , Humanos , Hipertensão/etiologia , Hipertensão/mortalidade , Masculino , Pessoa de Meia-Idade , Ensaios Clínicos Controlados Aleatórios como Assunto , Insuficiência Renal Crônica/mortalidade , Insuficiência Renal Crônica/fisiopatologia , Fatores de Risco , Análise de SobrevidaRESUMO
BACKGROUND: Postoperative hypotension and hypertension are frequent events associated with increased risk of adverse outcomes. However, proper assessment and management is often poorly understood. As a part of the PeriOperative Quality Improvement (POQI) 3 workgroup meeting, we developed a consensus document addressing this topic. The target population includes adult, non-cardiac surgical patients in the postoperative phase outside of the ICU. METHODS: A modified Delphi technique was used, evaluating papers published in MEDLINE examining postoperative blood pressure monitoring, management, and outcomes. Practice recommendations were developed in line with National Institute for Health and Care Excellence guidelines. RESULTS: Consensus recommendations were that (i) there is evidence of harm associated with postoperative systolic arterial pressure <90 mm Hg; (ii) for patients with preoperative hypertension, the threshold at which harm occurs may be higher than a systolic arterial pressure of 90 mm Hg; (iii) there is insufficient evidence to precisely define the level of postoperative hypertension above which harm will occur; (iv) a greater frequency of postoperative blood pressure measurement is likely to identify risk of harm and clinical deterioration earlier; and (v) there is evidence of harm from withholding beta-blockers, angiotensin receptor blockers, and angiotensin-converting enzyme inhibitors in the postoperative period. CONCLUSIONS: Despite evidence of associations with postoperative hypotension or hypertension with worse postoperative outcome, further research is needed to define the optimal levels at which intervention is beneficial, to identify the best methods and timing of postoperative blood pressure measurement, and to refine the management of long-term antihypertensive treatment in the postoperative phase.
Assuntos
Pressão Sanguínea/fisiologia , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Hipertensão/complicações , Hipotensão/complicações , Complicações Pós-Operatórias/fisiopatologia , Anti-Hipertensivos/uso terapêutico , Determinação da Pressão Arterial/métodos , Determinação da Pressão Arterial/normas , Técnica Delphi , Medicina Baseada em Evidências/métodos , Humanos , Hipertensão/diagnóstico , Hipertensão/tratamento farmacológico , Hipertensão/fisiopatologia , Hipotensão/diagnóstico , Hipotensão/fisiopatologia , Assistência Perioperatória/métodos , Assistência Perioperatória/normas , Prognóstico , Medição de Risco/métodosRESUMO
BACKGROUND: Continuous monitoring of arterial pressure is important in severely obese patients who are at particular risk for cardiovascular complications. Innovative technologies for continuous noninvasive arterial pressure monitoring are now available. In this study, we compared noninvasive arterial pressure measurements using the vascular unloading technique (Clearsight system; Edwards Lifesciences Corp, Irvine, CA) with invasive arterial pressure measurements (radial arterial catheter) in severely obese patients during laparoscopic bariatric surgery. METHODS: In 35 severely obese patients (median body mass index, 47 kg/m2), we simultaneously recorded noninvasive and invasive arterial pressure measurements over a period of 45 minutes. We compared noninvasive (test method) and invasive (reference method) arterial pressure measurements (sampling rate 1 Hz = 1/s) using Bland-Altman analysis (accounting for multiple measurements per subject), 4-quadrant plot/concordance analysis (2-minute interval, 5 mm Hg exclusion zone), and error grid analysis (calculating the proportions of measurements in risk zones A-E with A indicating no risk, B low risk, C moderate risk, D significant risk, and E dangerous risk for the patient due to the risk of wrong clinical interventions because of measurement errors). RESULTS: We observed a mean of the differences (±SD, 95% limits of agreement) between the noninvasively and invasively assessed arterial pressure values of 1.1 mm Hg (±7.4 mm Hg, -13.5 to 15.6 mm Hg) for mean arterial pressure (MAP), 6.8 mm Hg (±10.3 mm Hg, -14.4 to 27.9 mm Hg) for systolic arterial pressure, and 0.8 mm Hg (±6.9 mm Hg, -12.9 to 14.4 mm Hg) for diastolic arterial pressure. The 4-quadrant plot concordance rate (ie, the proportion of arterial pressure measurement pairs showing concordant changes to all changes) was 93% (CI, 89%-96%) for MAP, 93% (CI, 89%-97%) for systolic arterial pressure, and 88% (CI, 84%-92%) for diastolic arterial pressure. Error grid analysis showed that the proportions of measurements in risk zones A-E were 89.5%, 10.0%, 0.5%, 0%, and 0% for MAP and 93.7%, 6.0%, 0.3%, 0%, and 0% for systolic arterial pressure, respectively. CONCLUSIONS: During laparoscopic bariatric surgery, the accuracy and precision of the vascular unloading technique (Clearsight system) was good for MAP and diastolic arterial pressure, but only moderate for systolic arterial pressure according to Bland-Altman analysis. The system showed good trending capabilities. In the error grid analysis, >99% of vascular unloading technique-derived arterial pressure measurements were categorized in no- or low-risk zones.
Assuntos
Pressão Arterial/fisiologia , Cirurgia Bariátrica/normas , Determinação da Pressão Arterial/normas , Monitorização Intraoperatória/normas , Obesidade/cirurgia , Adulto , Cirurgia Bariátrica/métodos , Determinação da Pressão Arterial/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/métodos , Obesidade/fisiopatologia , Estudos ProspectivosRESUMO
Hypertensive disease and preeclampsia are serious medical disorders affecting pregnancy. Screening in early pregnancy may identify women at risk of developing hypertensive disease and enable prophylactic treatment. Accurate blood pressure measurement is an important part of this screening. The aim of this study was to investigate whether patients, with the aid of a context-aware sensor-based blood pressure self-measurement system, were able to correctly self-measure their blood pressure adhering to internationally established recommendations. Furthermore, to evaluate patient acceptance levels of performing self-measurements using context-aware adherence aids for guidance. A total of 100 pregnant women attending a routine ultrasound, at gestational week 12, at the outpatient clinic of the Department of Obstetrics and Gynecology, Aarhus University Hospital, were recruited in the waiting room before the scheduled scan. Blood pressure self-measurement was performed using a blood pressure self-measurement system called ValidAid consisting of a clinically approved blood pressure device, a sensor chair registering rest-time, back-supported, legs-crossed, and ambient noise levels respectively recording participant compliance, as well as a touch screen-based computer application with an interactive user interface for patient guidance and feedback, as well as a built-in decision support system. Acceptance of the automated self-measurement was evaluated by a questionnaire. In all, 99 percent followed the instructions with regard to both rest time and not talking. For both of these, ValidAid offered interactive and context-aware guidance. The recommendation of keeping legs uncrossed was only adhered to in 69 percent of measurements and back supported in 35 percent of measurements. For both of these, no interactive guidance was provided. The majority of the participants, 93 percent, felt comfortable using self-measurement equipment, while a minority of 8 percent would have preferred personnel-assisted measurements. The majority of participants were able to take reliable blood pressure self-measurements. Results indicate that recommendations that were not actively enforced were not followed to the same extent as those that were enforced. Thus, providing interactive context-aware guidance for all recommendations should be considered in the future. Furthermore, we found patient acceptance levels of performing self-measurements to be overall positive.
Assuntos
Determinação da Pressão Arterial/normas , Hipertensão/psicologia , Autogestão/métodos , Cooperação e Adesão ao Tratamento/psicologia , Adulto , Pressão Sanguínea , Determinação da Pressão Arterial/métodos , Determinação da Pressão Arterial/tendências , Feminino , Guias como Assunto , Humanos , Hipertensão/terapia , Programas de Rastreamento/métodos , Gravidez , Autogestão/psicologiaRESUMO
Blood pressure monitoring plays a key part in the preoperative, intraoperative, and postoperative care of all patients. In patients with obesity, hypertension indicates increased metabolic and surgical risk and may signal the presence of significant medical comorbidities, including obstructive sleep apnea. Avoidance of hypertension postoperatively is necessary to minimize bleeding risk after surgery. Hypotension in the postoperative period may be the first sign of significant complications that require urgent management. With the problem of being overweight or obese now affecting two-thirds of adults in Western countries, the proportion of patients with obesity in perioperative environments is similarly increasing. Detection of aberrations in blood pressure is contingent on the accuracy of blood pressure measurement methods. Patients with obesity tend to have a large arm circumference and "cone-shaped arms." Standard blood pressure cuffs fit such patients poorly, and this compromises the accuracy of measurements. Alternatives to arm blood pressure cuffs, some made specifically for individuals with obesity, have been evaluated but are not widely available to clinicians. This focused narrative review will discuss the relevance of hypertension management in the care of patients with obesity, highlight the currently available methods for perioperative monitoring of blood pressure, and explore the opportunities that exist to improve the perioperative blood pressure care in patients with obesity undergoing surgical procedures.