Article Impact Level: HIGH Data Quality: STRONG Summary of Circulation, CIR.0000000000001136. https://doi.org/10.1161/CIR.0000000000001136 Dr. Sudarshan Rajagopal et al.
Points
- Pulmonary hypertension (PH) during noncardiac surgery is on the rise in the US and is linked to adverse cardiovascular and cerebrovascular events.
- PH is classified into five groups based on the cause, and each group requires specific risk assessment and management.
- Predictors of perioperative complications in patients with PH include emergent procedures, elevated right atrial pressure, decreased 6-minute walking distance, and more.
- Preoperative optimization of PH includes a medical assessment and adjustment of PAH-specific therapies, diuretics, respiratory therapies, and arrhythmia management.
- Intraoperative PH management involves avoiding systemic hypotension, maintaining normal sinus rhythm, and avoiding factors that increase pulmonary vascular resistance, among other goals.
Summary
Pulmonary hypertension (PH) is an increasingly common condition in patients undergoing major noncardiac surgeries, and it is associated with significant adverse cardiovascular and cerebrovascular events. This Scientific Statement from the American Heart Association (AHA) guides the evaluation and management of PH in noncardiac surgery patients. PH is a heterogeneous group of disorders that can be classified into five groups, and predictors of perioperative complications include emergent procedures, elevated right atrial pressure, decreased 6-minute walking distance, and elevated N-terminal pro–B-type natriuretic peptide levels.
For preoperative risk assessment, the recommendations vary by PH group. For example, pulmonary arterial hypertension (PAH) patients should be evaluated by a PH specialist with risk assessment utilizing clinical risk scores. In contrast, group 2 PH patients should utilize cardiac preoperative scores to estimate perioperative risk. The optimization of PH prior to surgery should include medical assessment and adjustment of PAH-specific therapies, diuretics, respiratory therapies, participation in pulmonary rehabilitation, and arrhythmia management.
During surgery, the goals are to avoid systemic hypotension, maintain normal sinus rhythm, avoid factors known to increase pulmonary vascular resistance (PVR), maintain RV loading conditions, and choose the appropriate type of anesthesia. Monitoring with an invasive arterial catheter is recommended, and patients on parenteral PAH-specific therapy should continue it without interruption. Postoperative management should focus on avoiding conditions that can cause an elevation in PVR, optimizing pain control, and using inotropes to manage cardiogenic shock from RV failure. Inhaled pulmonary vasodilators can be used to lower PVR, and VV-ECMO can be used to improve oxygenation. VA-ECMO is the usual mechanical support modality for refractory RV failure refractory to medical therapy and can be used as a bridge to decision-making.
Link to the article: https://www.ahajournals.org/doi/10.1161/CIR.0000000000001136
References Rajagopal, S., Ruetzler, K., Ghadimi, K., Horn, E. M., Kelava, M., Kudelko, K. T., Moreno-Duarte, I., Preston, I., Rose Bovino, L. L., Smilowitz, N. R., Vaidya, A., & on behalf of the American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, and the Council on Cardiovascular and Stroke Nursing. (2023). Evaluation and Management of Pulmonary Hypertension in Noncardiac Surgery: A Scientific Statement From the American Heart Association. Circulation, CIR.0000000000001136. https://doi.org/10.1161/CIR.0000000000001136
