Post on 30-May-2018
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Perioperative Cardiovascular Evaluationand Management for Noncardiac Surgery
REFERENCES:
Circulation 2002;105:1257-68 OR
J Am Coll Cardiol 2002;39:542-53. http://www.acc.org/clinical/topic/topic.htm#guidelines
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Purpose of Preoperative Cardiac EvaluationPurpose of Preoperative Cardiac Evaluation
Define patients current cardiac status.
Assess and project perioperative CV risk.
Determine if preoperative testing is needed to
define cardiovascular status - recommended onlyif it will change surgical care or perioperativemedical therapy.
Initiate management to minimize cardiac riskover theentire perioperative period, andsubsequently.
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General Approach to the Patient - HistoryGeneral Approach to the Patient - History
Have you ever had any problem with your heart or arteries?
Do you exercise? Typical responses I try to. Translation: No.
Not as much as I should. Translation: No. Im active. Translation: No.
What exercise do you do? Tell me the most physically strenuous thingyou did in the last 2 weeks.
Is there real (exertional) angina, recent or past MI, HF, documented
arrhythmia, pacemaker or ICD? Any history or other indicators of atherosclerotic vascular disease?
CAD risk factors and doses of risk factors
unexplained, inordinate dyspnea
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ExerciseExercise capacity
capacity integrates theintegrates the
physiologic effects of all the patientsphysiologic effects of all the patientscombined cardiac abnormalities.combined cardiac abnormalities.
If history revealsIf history reveals
GOOD EXERCISE CAPACITY,GOOD EXERCISE CAPACITY,
then the patients operative risk is low.then the patients operative risk is low.
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General Approach to the PatientGeneral Approach to the Patient
Physical Examination general appearance,Physical Examination general appearance,
bruits, rales, elevated JVP, heart rate & rhythm,bruits, rales, elevated JVP, heart rate & rhythm,
murmurs of severe AS or MSmurmurs of severe AS or MS
Comorbidity: renal impairment, diabetes,Comorbidity: renal impairment, diabetes,
pulmonary diseasepulmonary disease
Basic Metabolic Panel, CBC, BNP, ECG, CXRBasic Metabolic Panel, CBC, BNP, ECG, CXR
BNP level (precise role in risk assessment andBNP level (precise role in risk assessment andpost-op management remains to be defined)post-op management remains to be defined)
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Q: Which cardiac conditions worry me most?Q: Which cardiac conditions worry me most?
A:A: SevereSevere stenotic (flow-limiting)stenotic (flow-limiting) lesions:lesions: coronary - diseasecoronary - disease severityseverity andand extentextent
AS > MSAS > MS severe pulmonary hypertensionsevere pulmonary hypertension
Regurgitant valvular lesions are rarely a problemperioperatively.
I am less concerned about CHF or arrhythmia in theabsence of ischemia. Both are readily treated and usuallywithout permanent sequelae, unlike MI and death.
AF is, however, a potentially costly (in money andmorbidity) nuisance. Avoid it.
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Patient-specific Clinical Predictors of IncreasedPatient-specific Clinical Predictors of Increased
Perioperative Cardiovascular RiskPerioperative Cardiovascular Risk(ACC/AHA Guidelines)(ACC/AHA Guidelines)
Major Acute coronary
syndromes
Decompensated CHF Significant (?)
arrhythmias
Intermediate Mild (?) angina pectoris Prior MI
Minor Advanced age. Abnormal ECG. Rhythm other than
sinus. Low functional
capacity.
History of stroke. Uncontrolled HTN
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Type of Surgery and Risk - IType of Surgery and Risk - I
Urgency: emergent, urgent/soon, elective Influences not only risk, but also your pre-op testing
(if any) strategy.
HIGH SURGICAL RISK:HIGH SURGICAL RISK: emergent major operations, esp. in elderly aortic and other major vascular surgery peripheral vascular surgery
BIG SURGERY: anticipated prolonged surgicalprocedures associated with large fluid shifts and/orblood loss, and long recovery.
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Type of Surgery and Risk - IIType of Surgery and Risk - II
Intermediate risk:
carotid
head and neckintraperitoneal
intrathoracic
orthopedicprostate
Low risk:
endoscopy
superficial procedurescataract surgery
breast surgery
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poor or unknown functional capacity: cant exercise,dont exercise
known or suspected CAD:angina, prior MI based onhistory or pathological Q waves, CAD-equivalent(peripheral vascular disease), risk factor profile
known or suspected significant AS, MS, pulmonary HTN
high surgical risk procedure: aortic or peripheral
vascular, BIG SURGERY
Preoperative non-invasive testing inPreoperative non-invasive testing in
known or suspected CAD - Which patient?known or suspected CAD - Which patient?
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Preoperative non-invasive testingPreoperative non-invasive testing
in known or suspected CAD - Which test?in known or suspected CAD - Which test?
rest echocardiography: but little insight into CAD
simple treadmill: exercise capacity
stress or dobutamine echo but dobutamine in aortic aneurysm ???
myocardial perfusion imaging - exercise or
dipyridamole
EXERCISE WHENEVER POSSIBLE.
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Recommendations for Coronary Angiography inRecommendations for Coronary Angiography in
Perioperative EvaluationPerioperative Evaluation (ACC/AHA Guidelines)(ACC/AHA Guidelines)
Class I: Patients with suspected or known CAD Evidence for high risk of adverse outcome based on
noninvasive test results
Angina unresponsive to adequate medical therapy
Unstable angina, particularly when facing intermediate-risk or high-risk noncardiac surgery
Equivocal noninvasive test results in patients at high-clinical risk undergoing high-risk surgery
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Q. When is revascularization (PCI, CABG)Q. When is revascularization (PCI, CABG)
recommended ?recommended ? (ACC/AHA Guidelines)(ACC/AHA Guidelines)
A. Generally only when justified by the usual clinicalA. Generally only when justified by the usual clinical
factors, apart from planned non-cardiac surgery.factors, apart from planned non-cardiac surgery.
No randomized trials document decreased perioperativecardiac events.
No prospective studies have determined optimal period of
delay after PCI before noncardiac surgery. Delay of 2-4 weeks after PCI with stent placement is
supported by observational study.
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Preoperative Therapy with B-BlockersPreoperative Therapy with B-Blockers(ACC/AHA Guidelines)(ACC/AHA Guidelines)
Class I indications
When B-blockers have been required in recent past forangina, symptomatic arrhythmia or hypertension.
Do not withdraw beta-blockade preoperatively. Patients undergoing vascular surgery with ischemia on
preoperative testing
Class IIa
When preoperative assessment identifies untreatedhypertension, known CAD, or major CAD risk factors.
Class III: contraindication to B-blockade
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Start pre-op, titrate to HR 50-60 bpm Short acting beta-blockers provide more flexible
dosing Give orally, if possible, with IV supplementation
when patient is NPO
Preoperative Therapy with B-BlockersPreoperative Therapy with B-Blockers(ACC/AHA Guidelines)(ACC/AHA Guidelines)
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Anesthetic Considerations andAnesthetic Considerations and
Intraoperative ManagementIntraoperative Management (ACC/AHA Guidelines)(ACC/AHA Guidelines)
No study clearly demonstrates improved outcome from : regional versus general anesthesia pulmonary artery catheter
intraoperative nitroglycerin ST-segment monitoring TEE prophylactic intra-aortic balloon pump
Choice of anesthetic and intraoperative monitoring is bestleft to discretion of anesthesia care team.
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Perioperative SurveillancePerioperative Surveillance (ACC/AHA Guidelines)(ACC/AHA Guidelines)
Post operative myocardial ischemia: Strongest predictor of perioperative cardiac morbidity. Often untreated until overt symptoms develop. Diagnosis of perioperative MI has short and long-term prognostic value.
30% to 50% perioperative mortality and reduced long-term survival.
For patients with known or suspected CAD, undergoing high orintermediate risk procedure:
Check ECG at baseline, immediately after procedure, and daily x 2 days.
Check cardiac troponin measurements 24 hours postoperatively and onday 4, or hospital discharge (whichever comes first).
Consider troponion also days 2 & 3.
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Pacemakers & ICDsPacemakers & ICDs
Electrocautery can cause oversensing, resultingin failure to pace or an inappropriate shock froman ICD.
Contact Cardiology.
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ConclusionsConclusions (ACC/AHA Guidelines)(ACC/AHA Guidelines)
Insure good communication between surgeon, anesthesiologist,primary care physician, and consultant.
Further cardiac testing and treatments generally are thesame as in the non-operative setting, considering:
the urgency of the noncardiac surgery patient-specific risk factors surgery-specific factors
Preoperative testing: when surgical risk is high. when patient-specific and surgery-specific risks are intermediate. when results will affect patient management.
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Questions you should always ask yourselfQuestions you should always ask yourself
Is there CAD?
If there is,
how severe? how extensive?
how active?
How big is the
surgery?
Is there severe AS, MS
pulmonary hypertension