Cardiac Clearance

Question 1

Who is ‘at risk’ for elevated cardiac risk

Answer 1

Hx MI/stents
angina
smokers
HTN
Hyperlipidemia
fhx CAD
valvular dz
hx CHF
hc arrhythmias
hx CVD
PVD
DM

Question 2

Who has major risk factors for peri-op MI

Answer 2

recent MI
unstable angina
uncontrolled CHF
severe valvular disease
uncontrolled HTN

Question 3

Who has moderate risk factors for peri-op MI

Answer 3

chronic stable CHF
arrhythmia
hx ischemic heart dz
hx stroke/TIA

Question 4

What should you look for at H&P with concerns for CV concerns

Answer 4

chest pain (exertional)
dyspnea (at rest of exertion)
orthopnea
edema
palpitations
recent syncope
new/changing murmur
irregular rate/rhythm

Question 5

What is the initial screening done for CV pre-op

Answer 5

routine EKG screening for ages 45+, symptomatic or otherwise high risk

Question 6

When would a echo be preferred for evaluation

Answer 6

unexplained dyspnea
HF with cahnge in last year and no recent testing
significant valvular disease
high risk surgeries
systolic dysfunction, LVH, mitral regurg, aS, LVEF <30%= high risk

Question 7

what are the stress testing options

Answer 7

exercise stress testing (EKG)
pharmcologic stress testing (EKG)
dobutamine stree echo

Question 8

What constitutes a ‘positive’ stree test?

Answer 8

ST depression >1mm in multiple leads
new BBB
new high grade AV block
Sustained VT or vfib
new or increasing frequency PVCs
supraventricular tachyarrhythmia

Question 9

what constitutes a positive stress echo

Answer 9

abnormal wall motion with exercise

Question 10

what should be considered if stress testing demonstrates ischemia

Answer 10

coronary angiography

only indicated if it will change surgical treatment

Question 11

What are the biomarkers

Answer 11

BNP, Troponins
(not routinely recommended for preop)

Question 12

what are modifiable CV risk factors that we can optimize

Answer 12

smoking cessation
good BP control
normalization of lipids
treatment of afib

Question 13

how should beta blockers be managed prior to surgery

Answer 13

mortality BENEFIT in peri-op period
BB withdrawal can induce HTN and ischemia
should be continued
can hold a dose post-op if hypotensive

Question 14

how should ACE inhibitors / ARBs be managed prior to surgery

Answer 14

typically, hold AM of surgery - risk of significant hypotension
resume as soon as possible post op (within 48hr)
hold for post-op hypotension
risk for peri-op renal injury

Question 15

how should Diuretics be managed prior to surgery

Answer 15

risk for peri-operative hypotension, hypokalemia, renal injury
hold AM of surgery, unless CHF and hard to control fluid status

Question 16

How should cholesterol-lowering meds (except statins) be managed prior to surgery

Answer 16

risk for myopathy/rhabdomyolysis
optimal discontinuation time controversial
hold day before or day of surgery, resume post-op
some high risk pts, initiate prior to surgery

Question 17

how should CCBs/Nitrates/Alpha-2 agnoists/Statins and Digoxin be managed prior to surgery

Answer 17

continue through peri-op period

Question 18

What needs to be done if a patient has a stent already prior to elective non-cardiac surgery?

Answer 18

delay 12 months after drug-eluting stent
delay 30-90 days after bare metal stenting
delay 2 weeks after balloon angioplasty
higher risk for MI or stent thrombosis