Flashcards in CV Assessment Deck (92)
Steps of the cardiac assessment
1) Determine the urgency of surgery
2) Determine if the patient has an active cardiac condition
3) Determine surgical risk (risk that the surgery will further damage the heart)
4) Assess functional capacity (exercise tolerance, etc)
5) Assess clinical predictors/markers
What is the goal of the pre-op cardiac assessment?
To identify patients with heart disease who are at high risk for perioperative morbidity or mortality or those with modifiable conditions or risks
Minor clinical predictors of increased CV risk
>75 years old
Low exercise tolerance
History of CVA
Rhythm other than NSR
Intermediate clinical predictors of increased CV risk
Prior MI (OVER one month ago) and Q waves on EKG
Mild, stable angina
Compensated or previous LV failure/CHF
DM (both insulin dependent AND non-insulin dependent)
Chronic renal insufficiency (CR > 2.0)
MAJOR clinical predictors of increased CV risk
These are major, current cardiac conditions
- Unstable coronary syndromes (active ischmia on EKG)
- MI within the last month
- Severe or unstable angina
- Decompensated CHF
- Significant arrhythmias (arrhythmias that are symptomatic)
- Severe valvular disease
What valvular disease are we most concerned about when it comes to intraoperative management?
Special considerations for cardiac assessment of Emily Rucker
She is a heartless creature, and therefore does not require a pre-op cardiac assessment.
What is the overall mortality risk of acute MI for the average person receiving GA?
The risk increases if the patient is undergoing intra-thoracic or intra-abdominal surgery or for surgeries lasting longer than 3 hours
Risk of periop reinfarction for those with history of prior acute MI
> 6 months ago = 6%
3-6 months ago = 15%
Within 3 months = 30%
Highest risk is within 30 days after acute MI
Mortality rate for perioperative reinfarction
ACC/AHA guidelines suggest waiting AT LEAST _______ post-MI before having elective surgery
This also allows us time to identify which areas of the myocardium will be most at risk during surgery
Surgeries with high risk of cardiac morbidity/mortality (>5% additional risk)
Aortic surgery (or surgery on other major vasculature)
Peripheral vascular surgery
Major emergent operations (especially for the elderly)
Prolonged procedures with major fluid shift/blood losses
Surgeries with intermediate risk of cardiac morbidity/mortality (1-5% additional risk)
Head and neck
Major neuro / ortho cases
Endovascular aneurysm repair
Surgeries with low risk of cardiac morbidity/mortality (<1% additional risk)
Basic components of the cardiac assessment
Patient history (and medication history)
Resting 12-lead EKG (only if indicated!!)
Who is indicated for a pre-op 12-lead EKG?
Patients with clinical indicators of CV disease
A 12-lead, if needed, should be done within ____days of surgery
Adjunct testing that can be done for a cardiac assessment
What is the gold standard for visualizing coronary anatomy?
Why is taking a good cardiac history important?
Because most of the time, history can diagnose if someone is at risk for cardiac events intra-op.
Patients with this type of angina are at a much higher risk of a cardiac event
What do we want to know about a patient's angina?
What are the precipitating factors?
How often does it occur? Duration of the pain? What relieves it (rest, medication, etc)?
What is the difference between stable and unstable angina?
Stable is predictable. Usually occurs during exercise or stress.
Unstable is unpredictable. May happen at rest or with light activity. It is a major predictor that an MI may occur soon.
Why is estrogen status of a female important to the CV history?
Estrogen has a protective factor against CV disease. Post-menopausal women are therefore at higher risk of a periop event.
In the absence of lung disease, this is the most striking evidence of decreased cardiac reserve
decreased exercise tolerance
What is the duke activity status index?
A questionnaire that is able to measure functional capacity (exercise tolerance) and how much O2 demand the heart is able to tolerate
Findings of the Duke Activity Status Index and what they mean
1-4 METS (eating, dressing, walking around the house, dishwashing)
4-10 METS (climbing stairs, walking around the neighborhood, heavy housework, golfing, bowling, dancing)
>10 METS (strenuous sports such as swimming, tennis, running, football, basketball, etc)
Patients unable to meet a 4-MET demand are at higher cardiac risk
Patients with this disorder may experience angina despite having healthy coronaries
A spasm of this can result in angina-like pain that is also relieved by NTG