Anaesthesia & Non-cardiac Surgery Flashcards
Most common time for occurrence of perioperative MI in a patient undergoing non-cardiac surgery is?
24-48 hours
Type 1 MI?
Plaque rupture (spontaneous MI)
Type 2 MI?
Demand supply mismatch MI
Which is the most common type of MI in peri-operative period?
Demand supply mismatch (Type 2 MI)
Most occur within how many hours of surgery during the greatest postoperative stress?
24-48 hours
What is the mechanism of Type 1 MI?
Rupture of a coronary plaque leads to platelet aggregation and thrombus formation.
What is the mechanism of Type 2 MI?
Prolonged imbalance between myocardial O₂ supply and demand in the setting of CAD.
What is the predominant type of perioperative MI?
Type 2 MI
Plaque rupture occurs in how much of perioperative MI cases?
0.5
Plaque rupture is associated with which conditions?
STEMI, NSTEMI
What are the characteristics of unstable coronary plaques?
Sympathetic hyperactivity (increased plasma catecholamines), Hemodynamic instability (Tachycardia/Hypertension), Coronary vasoconstriction
What are the two outcomes of coronary vasoconstriction in unstable coronary plaques?
Plaque rupture, Plaque erosion
What does acute coronary thrombosis lead to?
Acute Coronary Thrombosis → ACS (Acute Coronary Syndrome) → Type I MI
What does DSMM stand for in the context of severe, yet stable CAD?
Demand Supply Mismatch
What factors increase myocardial O₂ demand in DSMM?
Sympathetic hyperactivity, Postoperative pain, Withdrawal of β-blockers, Hypovolemia, Cardiac decompensation, Systemic vasodilation, Increased heart rate/arrhythmia
What factors affect subendocardial O₂ supply in DSMM?
Hypotension, Myocardial wall stress, Coronary vasoconstriction, Anemia, Hypoxemia
What does prolonged ST-depression ischemia lead to?
Type II MI
What is the most common scoring method for risk stratification in patients undergoing non-cardiac surgery?
Revised Cardiac Risk Index (RCRI)
What are the 6 independent predictors of major cardiac complications in RCRI?
- High-risk type of surgery, 2. History of ischemic heart disease, 3. History of heart failure, 4. History of cerebrovascular disease, 5. Diabetes mellitus requiring insulin therapy, 6. Preoperative serum creatinine > 2.0 mg/dL
What are examples of high-risk types of surgery?
Vascular surgery, open intraperitoneal or intrathoracic procedures
What constitutes a history of ischemic heart disease?
History of myocardial infarction, positive exercise test, chest pain secondary to ischemia, nitrate therapy, pathological Q waves on ECG
What is a note regarding prior coronary revascularization procedures in ischemic heart disease?
Do not count prior coronary revascularization unless other criteria for ischemic heart disease are present
What symptoms and criteria indicate a history of heart failure?
Dyspnea > II, Framingham criteria, pedal edema, orthopnea, JVP
What constitutes a history of cerebrovascular disease?
TIA/Stroke
What is the criterion for diabetes mellitus requiring treatment with insulin?
DM with insulin therapy
What is the threshold for preoperative serum creatinine in RCRI?
Creatinine > 2.0 mg/dL (177 µmol/L)
Is Left Ventricular Ejection Fraction (LVEF) a predictor in RCRI?
No
What is the rate of cardiac death, nonfatal MI, and nonfatal cardiac arrest with no risk factors according to RCRI?
0.004
What is the rate of cardiac death, nonfatal MI, and nonfatal cardiac arrest with 1 risk factor according to RCRI?
0.01
What is the rate of cardiac death, nonfatal MI, and nonfatal cardiac arrest with 2 risk factors according to RCRI?
0.024
What is the rate of cardiac death, nonfatal MI, and nonfatal cardiac arrest with 3 or more risk factors according to RCRI?
0.054000000000000006
What is the rate of myocardial infarction and other events (excluding death) with no risk factors according to RCRI?
0.005
What is the rate of myocardial infarction and other events (excluding death) with 1 risk factor according to RCRI?
0.013000000000000001
What is the rate of myocardial infarction and other events (excluding death) with 2 risk factors according to RCRI?
0.036000000000000004
What is the rate of myocardial infarction and other events (excluding death) with 3 or more risk factors according to RCRI?
0.091
What are the components of the AUB-HAS2 cardiovascular risk index related to heart disease?
History of heart disease, Symptoms of heart disease (Angina or dyspnea)
What are the components of the AUB-HAS2 cardiovascular risk index related to age or anemia?
Age ≥ 75 years, Anemia (Hemoglobin < 12 mg/dl)
What types of surgery are included in the AUB-HAS2 index?
Emergency Surgery, Vascular Surgery
How does the AUB-HAS2 index stratify patients into risk groups?
Low risk (score 0-1), Intermediate risk (score 2-3), High risk (score > 3)
What makes the AUB-HAS2 index superior to the RCRI?
The AUB-HAS2 index was shown to be superior in performance to RCRI.
Who can effectively use the AUB-HAS2 cardiovascular risk index?
Busy physicians in clinics or nurses in preadmission units
What surgeries are considered high risk for cardiac events (reported cardiac risk >5%)?
Aortic and other major vascular surgery, Peripheral vascular surgery
What surgeries are considered intermediate risk for cardiac events (reported cardiac risk 1%-5%)?
Intraperitoneal and intrathoracic surgery, Carotid endarterectomy, Head and neck surgery, Orthopedic surgery, Prostate surgery
What surgeries are considered low risk for cardiac events (reported cardiac risk <1%)?
Endoscopic procedures, Superficial procedure, Cataract surgery, Breast surgery, Ambulatory surgery
What is the cardiac risk for patients undergoing non-cardiac surgery classified as high risk?
> 5%
What is the cardiac risk for patients undergoing non-cardiac surgery classified as intermediate risk?
1%-5%
What is the cardiac risk for patients undergoing non-cardiac surgery classified as low risk?
<1%
What is the risk of intraperitoneal surgery according to Braunwald/ESC?
Intermediate risk
How is intraperitoneal/intrathoracic surgery classified according to RCRI?
High risk
What surgeries are considered low risk for cardiac events (reported cardiac risk <1%)?
Superficial surgery, Breast surgery, Dental surgery, Endocrine (thyroid surgery), Eye surgery, Reconstructive surgery, Carotid asymptomatic (CEA or CAS), Gynecology (minor surgery), Orthopedic (minor, meniscectomy), Urological (minor, TURP), Endoscopic procedures, Cataract surgery
What surgeries are considered intermediate risk for cardiac events (reported cardiac risk 1%-5%)?
Intraperitoneal surgery, Splenectomy, Hiatal hernia repair, Cholecystectomy, Carotid symptomatic (CEA or CAS), Peripheral arterial angioplasty, Endovascular aneurysm repair, Head and neck surgery, Neurological or orthopedic (major, hip and spine surgery), Urological or gynecological (major), Renal transplant, Intrathoracic surgery (non-major)
What surgeries are considered high risk for cardiac events (reported cardiac risk >5%)?
Aortic and major vascular surgery, Open lower limb revascularization or amputation or thrombo-embolectomy, Duodeno-pancreatic surgery, Liver resection, bile duct surgery, Esophagectomy, Repair of perforated bowel, Adrenal resection, Total cystectomy, Pneumonectomy, Pulmonary or liver transplant
What was the effect of administering aspirin before surgery and throughout the early postsurgical period?
Had no significant effect on the rate of a composite of death or nonfatal myocardial infarction.
What trial studied the administration of aspirin before surgery and throughout the early postsurgical period?
POISE-2 trial
What is the recommendation for aspirin before surgery according to the POISE-2 trial?
Class 2a
What was the outcome of the POISE-2 trial regarding aspirin administration?
Neutral (+ve)
What was the effect of spironolactone according to the TOPCAT trial?
Significantly reduced the incidence of the primary composite in patients with heart failure and a preserved ejection fraction.
What was the outcome of the TOPCAT trial for spironolactone?
Positive (+ve)
What was the effect of renal artery denervation in the SIMPLICITY HTN-3 trial?
Did not show a significant reduction of systolic blood pressure in patients with resistant hypertension.
What was the outcome of the SIMPLICITY HTN-3 trial for renal artery denervation?
Negative (-ve)
What was the effect of early intervention with CRT-D according to the MADIT-CRT trial?
Associated with a significant long-term survival benefit in patients with mild heart-failure symptoms, left ventricular dysfunction, and left bundle-branch block.
What was the outcome of the MADIT-CRT trial for early CRT-D intervention?
Positive (+ve)
What medication must be continued before surgery despite minor bleeding risk?
Aspirin
What medications should be discontinued before surgery?
Clopidogrel, Ticagrelor
What is the recommendation for perioperative continuation of statins?
Perioperative continuation of statins is recommended, favoring statins with a long half-life or extended-release formulation.
What is the class recommendation for perioperative continuation of statins?
Class I
When should preoperative initiation of statin therapy be considered, and for what type of surgery?
Preoperative initiation of statin therapy should be considered in patients undergoing vascular surgery, ideally at least 2 weeks before surgery.
What is the class recommendation for preoperative initiation of statin therapy?
Class IIa
What is the recommendation for continuation of aspirin in the perioperative period?
Continuation of aspirin in patients previously treated with aspirin may be considered in the perioperative period based on the risk of bleeding and thrombosis.
What trial studied the perioperative continuation of aspirin?
POISE-2 trial
What is the class recommendation for perioperative continuation of aspirin according to the POISE-2 trial?
Class IIb
When should discontinuation of aspirin be considered in the perioperative period?
Discontinuation of aspirin should be considered in patients where hemostasis is anticipated to be difficult during surgery.
What is the class recommendation for perioperative continuation of beta blockers and statins?
Class I
What is the class recommendation for perioperative continuation of aspirin according to additional notes?
Class IIb
What should be done if ACS (Acute Coronary Syndrome) is present preoperatively?
Evaluate and treat according to GDMT.
What should be done if ACS is not present preoperatively?
Estimate perioperative risk of MACE (Major Adverse Cardiac Events) based on combined clinical/surgical risk.
What are two risk assessment methods used for preoperative cardiac risk?
RCRI (Revised Cardiac Risk Index) and AUB-HAS2 Score
What is the recommended action for low-risk patients (<1%)?
No further testing (Class III: NB); Proceed to surgery.
What is the recommended action for elevated-risk patients?
Further clinical management based on risk stratification.
What is the recommended approach for non-cardiac surgery in an emergency vs. elective situation?
Consider emergency vs. elective surgery. Use RCRI and AUB-HAS2 to estimate perioperative risk.
What functional capacity level (METs) does not require further testing before surgery?
Moderate or greater (≥4 METs). No further testing required (Class IIa). Proceed to surgery.
What is the recommended testing for patients with poor or unknown functional capacity (<4 METs)?
Pharmacologic stress testing (Class IIa).
What should be done if pharmacologic stress testing is normal?
Proceed to surgery.
What should be done if pharmacologic stress testing is abnormal?
Perform coronary angiography (CAG) to delineate coronary anatomy.
What is the purpose of coronary angiography (CAG) if abnormal stress test results occur?
CAG helps to delineate coronary anatomy and guide revascularization.
What are the recommendations for patients unable to do physiological stress testing (TMT)?
Pharmacologic stress testing (MPI) is recommended. If abnormal, perform CAG to delineate coronary anatomy and guide revascularization.
What activities are associated with 1 MET?
Take care of yourself, Eat, dress, or use the toilet, Walk indoors around the house, Walk a block or two on level ground at 2-3 mph (3.2-4.8 kph)
What activities are associated with 4 METs?
Do light work around the house (dusting or washing dishes), Climb a flight of stairs or walk up a hill, Walk on level ground at 4 mph (6.4 kph), Run a short distance, Do heavy work around the house (scrubbing floors or moving heavy furniture), Participate in moderate recreational activities (golf, bowling, dancing, doubles tennis, throwing a baseball or football)
What activities are associated with more than 10 METs?
Participate in strenuous sports (swimming, singles tennis, football, basketball, skiing)
What should be done if surgery is urgent according to the Preoperative Cardiac Risk Evaluation?
Patient- or surgical-specific factors dictate the strategy and do not allow further cardiac testing or treatment. Consultant provides recommendations on perioperative management and continuation of chronic cardiovascular medical therapy.
What are the next steps if surgery is not urgent in the Preoperative Cardiac Risk Evaluation?
Continue to Step 2.
What should be done if active or unstable cardiac conditions (UA/ACS) are present?
Treatment options should be discussed in a multidisciplinary team.
What are the options if the index surgical procedure can be delayed in a patient with active cardiac conditions?
Proceed for coronary artery intervention, with dual antiplatelet therapy.
What should be done if delay is not possible in a patient with active cardiac conditions?
Proceed directly to operation with optimal medical therapy.
What is the first step in determining the risk of a surgical procedure?
Determine the risk of the surgical procedure.
What should a consultant do for low-risk procedures according to ESC Guidelines?
Identify risk factors and provide recommendations on lifestyle and medical therapy.
What preoperative test may be considered for patients with one or more clinical risk factors?
Preoperative baseline ECG may be considered to monitor changes during the perioperative period.
What therapy may be initiated for patients with known ischemic heart disease or myocardial ischemia?
Initiation of a titrated low-dose beta blocker regimen.
What therapy should be considered for patients with heart failure and systolic dysfunction before surgery?
ACE inhibitors should be considered before surgery.
What therapy should be considered for patients undergoing vascular surgery before surgery?
Initiation of statin therapy should be considered.
What should be done if the patient’s functional capacity is ≥4 METs?
Proceed with surgery.
What should be done if the patient’s functional capacity is <4 METs?
Continue to Step 5.
What is recommended for patients with poor functional capacity (<4 METs) and intermediate-risk surgery?
Noninvasive stress testing may be considered.
What are two considerations for determining the risk of surgical procedures?
RCRI used to determine risk of surgical procedure, Emergency vs elective surgery considerations.
What is the next step if a patient has ≥3 cardiac risk factors?
Proceed to Step 7.
What should be done if a patient has ≤2 cardiac risk factors?
Consider additional evaluations such as rest echocardiography and biomarkers for LV function and prognostic information.
When should noninvasive testing be considered before surgery?
Considered prior to any surgical procedure for patient counseling or changes in perioperative management.
What should be done if noninvasive stress testing shows no/mild/moderate stress-induced ischemia?
Proceed with planned surgery.
What is recommended for patients with extensive stress-induced ischemia?
Individualized perioperative management is recommended, considering the potential benefit of surgery compared to adverse outcomes.
How long after balloon angioplasty can surgery be performed?
> 2 weeks after intervention with continuation of aspirin treatment.
How long after bare-metal stent (BMS) placement can surgery be performed?
≥4 weeks after stent placement with continuation of dual antiplatelet therapy (DAPT) for at least 4 weeks.
How long after drug-eluting stent (DES) placement can surgery be performed?
Within 12 months for old-generation DES and within 6 months for new-generation DES.
What antiplatelet therapy should continue before coronary artery bypass grafting (CABG)?
Continue SAPT (single antiplatelet therapy) before surgery.
What should be considered for aspirin management in the perioperative period?
Aspirin continuation or discontinuation should be based on the bleeding risk versus thrombotic risk.
When should Ticagrelor be stopped before surgery?
3 days prior to surgery.
What is special about Ticagrelor as an antiplatelet?
Ticagrelor is a reversible inhibitor of the P2Y12 receptor.
When should Clopidogrel be stopped before surgery?
5 days prior to surgery.
What is special about Clopidogrel as an antiplatelet?
Clopidogrel is an irreversible inhibitor.
When should Prasugrel be stopped before surgery?
7 days prior to surgery.
What is special about Prasugrel as an antiplatelet?
Prasugrel is an irreversible inhibitor.
What is the mnemonic for remembering when to stop antiplatelets before surgery?
TCP (Ticagrelor, Clopidogrel, Prasugrel) - 3, 5, 7 days before surgery.
When should antiplatelet therapy be restarted after surgery?
Day 1–4 after surgery.
What is the recommendation for surgery <30 days after bare-metal stent (BMS) implantation?
Class III: Harm — Delay surgery.
What is the recommendation for surgery ≥30 days after bare-metal stent (BMS) implantation?
Class I: Proceed with surgery.
How long is aspirin required after BMS implantation before surgery?
Single dose of aspirin daily is required for at least 4 weeks.
What is the recommendation for surgery <3 months (90 days) after drug-eluting stent (DES) implantation?
Class III: Harm — Delay surgery.
What is the recommendation for surgery 3–6 months after DES implantation?
Discontinue DAPT. Class IIb: Proceeding with surgery may be considered.
What is the recommendation for surgery ≥6 months after DES implantation?
Discontinue DAPT. Class I: Proceed with surgery.
What is the handwritten recommendation for BMS implantation ≥30 days?
Class I: Safe for non-cardiac surgery.
What is the handwritten recommendation for BMS implantation <30 days?
Class III: Delay surgery.
What is the handwritten recommendation for DES implantation <90 days?
<90 days (3 months) - Class III: Delay surgery.
What is the handwritten recommendation for DES implantation 3–6 months?
3–6 months - Class IIb: Surgery may be considered.
What is the handwritten recommendation for DES implantation >6 months?
> 6 months - Class I: Preferable for surgery.
What is the definition of a recent MI according to ACC guidelines?
MI within 60 days.
How does the ACC National Database Registry define recent MI?
MI occurring between 7 days to 1 month, but the latest 2014 guidelines state within 60 days.
What are the active cardiac conditions for which patients should undergo evaluation prior to non-cardiac surgery?
Recent MI, AF with FVR, Asymptomatic severe AS, Symptomatic severe MS.
Why does a recent MI within 60 days require evaluation before surgery?
Recent MI within 60 days indicates unstable coronary syndrome and will require evaluation.
What is the significance of AF with FVR in the context of non-cardiac surgery?
AF with FVR may be caused by rheumatic heart disease or mitral stenosis, which requires attention before surgery.
What is the risk associated with asymptomatic severe aortic stenosis (AS)?
Velocity > 5 m/s increases the risk of sudden cardiac death (SCD).
Why is symptomatic severe mitral stenosis (MS) a concern for non-cardiac surgery?
Patients with symptomatic severe MS may not be able to lie down for surgery.
What are the unstable coronary syndromes that require evaluation before non-cardiac surgery?
Unstable or severe angina (CCS class III or IV), Recent myocardial infarction (MI) <60 days
What heart failure conditions require evaluation before non-cardiac surgery?
NYHA functional class IV, Worsening or new-onset heart failure (HF)
What significant arrhythmias require evaluation before non-cardiac surgery?
High-grade atrioventricular block, Mobitz II atrioventricular block, Third-degree atrioventricular heart block, Symptomatic ventricular arrhythmias, Supraventricular arrhythmias with uncontrolled ventricular rate (>100 beats/min at rest), Symptomatic bradycardia, Newly recognized ventricular tachycardia
What defines severe valvular disease that requires evaluation before non-cardiac surgery?
Severe aortic stenosis (mean pressure gradient >40 mm Hg, aortic valve area <1.0 cm², or symptomatic), Symptomatic mitral stenosis (progressive dyspnea on exertion, exertional presyncope, or heart failure)
What additional note is provided for asymptomatic severe aortic stenosis (AS) or symptomatic mitral stenosis (MS) before surgery?
Asymptomatic severe aortic stenosis (AS) or symptomatic mitral stenosis (MS) should be sent for non-cardiac surgery without much evaluation.
