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What is the goal of pre-op cardiac assessment?

What are the 5 steps?

  • Goal: identify patients with heart disease who are at high risk for perioperative cardiac morbidity or mortality or those with modifiable conditions or risks
  • Steps:
    • 1. urgency of surgery
    • 2. determine if active cardiac condition
    • 3. determine surgical risk
    • 4. assess functional capacity
    • 5.  assess clinical predictors/markers


What are the clinical predictors of minor increased cardiovascular risk (7)

What is the chance of having an event?

  • HTN
  • abnormal ECG
  • smoking
  • increased age/male sex
  • hypercholesterolemia
  • rhythm other than sinus
  • family history
  • <1% chance of having an event


What are the clinical predictors for an intermediate increase in cardiovascular risk?

  • Known CAD
  • prior MI > 1 month and Q waves on ECG
  • history of mild, stable angina
  • compensated or previous LV failure/CHF
  • diabetes
  • chronic renal insufficiency
    • Cr > 2.0 mg/dL
  • Cerebrovascular disease 
    • stroke, TIA


What are the clinical predictors for a major cardiovascular risk?

  • unstable coronary syndromes
  • acute or recent MI <1 month
  • unstable or severe angina
  • decompensated CHF
  • significant arrhythmias
    • HB, afib (depending on how controlled the rate is), vtach
  • Severe valvular disease
    • mitral, aortic stenosis


What is the overall mortality risk of an acute MI after GA?

When is this risk increased?


Incidence is increased in the patient undergoing intrathoracic or intra-abdominal surgery or surgery lasting longer than 3 hours.


What is the risk of mortality with history of prior MI?

> 6 months ago?

3-6 months ago?

within three months?

within 7 days?

If reinfarction occurs?

  • > 6 months ago: risk is 6%
  • 3-6 months ago: risk is 10%
  • within 3 months: 30%
  • within 7 days: postpone surgery
  • If reinfarction occurs, the mortality rate is 50%


What is the higherst risk period after an MI?

What are the ACC/AHA guidelines?

  • Highes risk period is within 30 days after an acute MI
  • ACC/AHA guidelines recommend waiting at least 4-6 weeks before elective surgery


Which surgeries are high risk?

intermediate risk?

low risk?

  • High:
    • intraperitoneal
    • intrathoracic
    • aortic and other major vascular
    • emergent major operations (esp in elderly)
    • long procedures with large fluid shifts/loss
  • Intermediate
    • Carotid endarterectomy
    • peripheral vascular surgery
    • head and neck
    • neurologic/ orthopedic
    • endovascular aneurysm repair
  • low 
    • endoscopic procedures
    • superficial
    • biopsies
    • cataract
    • breast surgery, GYN


What is the "gold standard" test for coronary anatomy?

Coronary angiography


What do you want to try to figure out from the history, physical, and work up?

  • severity of cardiac disease
  • progression of the disease
  • what the patient's functional limitations are


What are some questions you might want to ask a pt you suspect of having cardiac disease?

  • Do you become short of breath when lying flat (orthopnea) or with exertion?
  • Have you ever has a heart attack or CHF?
  • Do you have angina or chest pain/tightness?
    • what precipitates it?
    • what are some associated symptoms?
    • how frequent? duration?
    • what relieves the pain?
  • Do you have irregular heart beats or palpitations?
  • pacemaker? ICD?
  • heart murmor?
  • Problems with BP or on any meds?


What are some more questions, not directly related to the heart that you would want to ask a cardiac patient?

  • DM?
  • renal insufficiency?
  • high cholesterol?
  • estrogen status? I.e. menopause- increased risk
  • age and weight?
  • fatigues?
  • syncope?
  • anemia?
  • smoker? alcohol?
  • illicit drug use?


How do you assess the pts functional capacity?

  • Exercise tolerance
    • if the pt has no lung disease, this is the most "striking" evidence of decreased cardiac reserve
  • Duke activity status Index
    • 1-4 METS: eating, dressing, walking around the house, dishwashing
    • 4-10 METS: climbing stairs, walk in neighborhood, heavy housework, golf, bowl, dance
    • >10: strenuous sports (swimming, tennis, running, football)
  • Those unable to meet a 4 MET demad are considered higher risk


What is a MET?

  • Metabolic equivalent of task
  • 1 MET = 3.5 mg/kg/min of O2 being consumed
  • 70 kg pt = 240 ml O2
    • This is the same minimum Oflow required for a closed circuit


What is Angina?

What are some other causes of Angina?

Stats about silent MIs

  • Angina- sign of imbalance between myocardial oxygen supply vs demand
  • Other causes:
    • Aortic stenosis- may have angina despite normal coronaries
    • Esophageal spasm- caused by heartburn can cause angina that is relieved by NTG
  • Silent MIs
    • approximately 80% of ischemic episodes in CAD pts occur without angina
    • Approximately 10-15% of acute MIs are silent


What is prinzmetal's angina?

  • Vasospastic angina that occurs at rest
  • 85% have a fixed proximal lesion in a major artery, 15% have just spasm
  • seen in pts with other vasospastic diseases:
    • migrains
    • Raynaud's


What do you need to know/do if your patient has a pacemaker and ICD?

  • Indication for the pacemaker or ICD
  • underlying rhythm and rate
  • type of pacemaker
    • demand- sends electrical pulses if HR is too slow
    • fixed- constant frequency
    • radiofrequency- can be hacked
    • chamber paced vs chamber sensed
  • When was the last time the pacemaker was interrogated by CIED? -prefer within last 3 months
    • note settings and battery life
  • Evaluate effect of magnet
  • Inactivate ICD tachyarrhythmia detection and put defibrillator pads on
    • to avoid having the ICD pick up other electricity in OR as a dysrhythmia


What can inhibit pacemaker firing in the OR?

What is the magnet for?

What should you monitor?

  • Electrocautery can have electromagnetic interference that can inhibit pacemaker firing
    • Bipolar electrocautery is preferred; avoid monopolar
  • Most pacemakers can be converted to a fixed rate (asynchronous mode) by placing a magnet over the pacemaker box
    • must have a magnet immediately available
    • Have external pacing available
  • Monitor some form of blood flow
    • pulse ok, A-line


Where should the grounding pads be?

As far from the pulse generator and leads as possible


What are you going to look for upon physical exam of a patient with heart disease?

  • Overall appearance
    • obesity
    • SOB
    • sternal incision, pacemaker box
  • Heart
    • sounds
    • Murmors
  • Neck
    • JVD
    • Carotid bruit
  • Lungs
    • sounds
    • SOB, effort
  • Vital signs- BP in both arms
  • Extremeties
    • peripheral edema
    • pulses
    • clubbing
    • skin color


How do you assess the different heart sounds? 


What is Erb's point?

Erb's point is where you can hear S1 and S2 equally


What is considered hypertension?

When should it be treated?


  • HTN is BP > 140/90
  • Treat if SBP >160 and DBP >90
    • Beta blockers may have protective benefit


If pt has long standing severe HTN or uncontrolled HTN, what might you need to do?

  • May need to delay surgery to control BP
    • need ECG and serum BUN/Cr
    • if on diuretics, CHEM 7
  • continue meds
  • Anxiolytic may help


What are the 2014 ACC/AHA recommendations regarding Beta blocker therapy?

  • Continue beta blocker therapy on pts who have been on chronic BB therapy
    • discontinuation may increase perioperative CV morbidity
  • Start BBs on high risk patients
    • >1 day prior to surgery, preferrably 2-7 days
    • can be harmful if started day of surgery


What is heart failure?

What can cause it?

When is it suspected

  • Heart failure- abnormal contractility or abnormal relaxation of the heart muscle
    • can be causd by HTN or Ischemic heart disease (IHD)
  • Suspected with:
    • orthopnea
    • nocturnal coughing
    • fatigue
    • peripheral edema
    • 3rd, 4th heart sounds
    • resting tachycardia 
    • rales
    • JVD
    • ascites
  • HF and LV dysfunction is high risk and elective surgery should be postponed


What kind of work up do you want to do for a patient with Heart failure?

What meds do you want to continue before surgery?

  • ECG
  • Chem 7, BUN/Cr
  • BNP (normal = <100 pg/ml
  • CXR if you suspect pulmonary edema
  • ECHO to objectively measure LVEF
  • Continue all medications except ACEs and ARBs


Which type of valvular abnormality poses the greatest risk?

What is the deal with diastolic murmors?

What if the pt has a prosthetic heart valve?

  • Aortic stenosis- valve area <1 cm2
    • if symptoms, postpone surgery
  • Diastolic murmors are always pathologic and require further evaluation
  • If pt has prosthetic heart valve
    • may need to bridge anticoagulant therapy
    • may need bacterial endocarditis prophylaxis


Which arrhythmias are associated with perioperative risk?


When should you postpone surgery?

  • SVT and ventricular arrhythmias are associated with perioperative risk
  • LBBB is strongly associated with CAD
    • if new, stress testing or consulatation is required
  • Postpone surgery if:
    • uncontrolled afib
    • ventricular tachycardia
    • new-onset atrial fibrillation
    • symptomatic bradycardia
    • high-grade or third degree HB


What medications are ppl with cardiac issues typically on?

  • beta blockers
  • statins
  • aspirin
  • CCB
  • nitro for angina
  • diuretics
  • antiarrhymics


What anticoagulant medications might your patient be on and when should you have them stop taking them?

  • Antiplatelet (ASA, Plavix)
    • discontinue 7-10 days prior
  • Anticoagulants (coumadin, LMWH)
    • discontinue Coumadin 3-5 days prior
    • discontinue LMWH 12 hours prior
    • want INR <1.5
    • may use heparin gtt as bridge therapy, stop 4 hours prior to surgery
  • Fibrinolytics (TPA, Streptokinase, Urokinase)
    • usually cannot discontinue