B P3 C23 Anesthesia and Noncardiac Surgery

Question 1

If the patient is clinically stable, identification of known _________ can foster the implementation of guideline-based risk reduction therapies

Answer 1

Asymptomatic or symptomatic stable CAD or risk factors for CAD

Question 2

In determining the extent of preoperative evaluation, it is important __________ testing unless the results will affect perioperative management.

Answer 2

Not to perform testing

Currently no significant adjunctive therapy that ameliorates cardiovascular surgical risk.

In addition, the use of medications or interventions should mirror those that would be implemented in the absence of surgery.

Question 3

The primary reason to perform risk assessment is to determine _________ and _________

Answer 3

Determine clinical cardiovascular instability and suitability for surgery.

Question 4

Multiple older studies have demonstrated an increased incidence of reinfarction after noncardiac surgery if the previous MI had occurred ___________ of the operation

Answer 4

Within 6 months

Question 5

The AHA/ACC Task Force on Perioperative Evaluation of the Cardiac Patient Undergoing Noncardiac Surgery has suggested that the highest-risk patients are those within _________days of MI, during which time plaque and myocardial healing occur.

Answer 5

Within 30 days of MI

Question 6

A hypertensive crisis in the postoperative period—defined as diastolic BP __________ and clinical evidence of ___________—poses a definite risk for MI and cerebrovascular accident (CVA, stroke).

Answer 6

Higher than 120 mm Hg

Impending or actual end-organ damage

Similarly, intraoperative hypotension is associated with both type 2 MI and increases in postoperative mortality.

Question 7

Iatrogenic precipitants of hypertensive crises include

Answer 7

Abrupt withdrawal of clonidine or beta blocker therapy before surgery
Chronic use of monoamine oxidase inhibitors with or without sympathomimetic drugs
Inadvertent discontinuation of antihypertensive therapy

Question 8

In the Intraoperative Norepinephrine to Control Arterial Pressure (INPRESS) study, a multicenter, randomized, clinical trial of an individualized management strategy aimed at achieving a _______________ or standard management strategy of treating systolic BP less than 80 mm Hg or lower than 40% from the reference value during and for 4 hours following surgery.

Among 292 patients who completed the trial, management targeting an individualized systolic BP, compared with standard management, reduced the risk of postoperative organ dysfunction.6

Answer 8

Systolic BP within 10% of the reference value (i.e., patient’s resting systolic BP)

Question 9

The preoperative evaluation should aim to identify the underlying coronary, myocardial, and valvular heart disease and assess the severity of _______ and ________

Answer 9

Systolic and diastolic dysfunction

Question 10

_______ HF is associated with a significant increase in postoperative morbidity and mortality when controlling for other comorbidities

Answer 10

Worsening preoperative HF

In the absence of a surgical e gency, patients with decompensated HF should be treated to achieve a euvolemic, stable state before operation. Ischemic cardiomyopathy is of greatest concern because the patient has the additional substantial risk for the development of further ischemia, which can lead to myocardial necrosis and potentially induce a downward spiral.

Question 11

_______ is associated with the highest risk for cardiac decompensation in patients undergoing elective noncardiac surgery

Answer 11

Critical aortic stenosis

Thus, the presence of any of the classic triad of angina, syncope, and HF in a patient with aortic stenosis should prompt further evaluation and potential interventions (usually valve replacement)

Question 12

________ is a bridging option for selected patients who cannot undergo valve replacement or percutaneous intervention in the short term.

Answer 12

Aortic valvuloplasty

Question 13

_______ is associated with a lower risk for perioperative complications than aortic stenosis,

Answer 13

Mitral valve disease

Question 14

In perioperative patients with a functioning prosthetic heart valve, __________ and _________ require management

Answer 14

Antibiotic prophylaxis and anticoagulation

Question 15

Common practice in patients undergoing noncardiac surgery with a mechanical prosthetic valve in place is cessation of warfarin ________

Answer 15

3 days before surgery

Question 16

Oral anticoagulants can then be resumed on postoperative ________

Answer 16

Day 1

Question 17

According to the 2020 AHA/ACC guidelines on management of valvular heart disease, 9heparin can usually be reserved for high-risk patients.

High risk is defined by

Answer 17

Presence of a mechanical mitral or tricuspid valve
Mechanical aortic valve in the presence of certain risk factors, including AF, previous thromboembolism, hypercoagulable condition
Older-generation mechanical valves
Ejection fraction lower than 30%
More than one mechanical valve

Bridging anticoagulation therapy with heparin during the preoperative time interval when the INR is subtherapeutic should be made on an individualized basis, with the risks of bleeding weighed against the benefits of thromboembolism prevention.

The 2020 ACC/AHA guidelines also note that it is reasonable to consider the need for bridging anticoagulant therapy around the time of invasive procedures in patients with bioprosthetic heart valves or annuloplasty rings who are receiving anticoagulation for AF on the basis of the CHA2DS2-VASc score weighed against the risk of bleeding.

Question 18

________ and _______ present a major concern in patients with congenital heart disease.

Answer 18

Pulmonary hypertension and Eisenmenger syndrome

Question 19

________ has traditionally been avoided in these patients because of the potential for sympathetic blockade and worsening of the right-to-left shunt

Answer 19

Regional anesthesia

Question 20

Cardiac arrhythmias frequently occur in the perioperative period, particularly in older adults or patients undergoing thoracic surgery.

Predisposing factors include

Answer 20

Previous arrhythmias
Underlying heart disease
Hypertension
Perioperative pain (e.g., hip fractures)
Severe anxiety, and other situations that heighten adrenergic tone

Question 21

Examples of High (reported cardiac risk often >5%) Risk Surgical Procedures

Answer 21

Aortic and other major vascular surgery

Peripheral vascular surgery

Question 22

Examples of intermediate (reported cardiac risk often 1-5%) Risk Surgical Procedures

Answer 22

Intraperitoneal and intrathoracic surgery

Carotid endarterectomy

Head and neck surgery

Orthopedic surgery

Prostate surgery

Question 23

Examples of low (reported cardiac risk often <1%) Risk Surgical Procedures

Answer 23

Endoscopic procedures

Superficial procedure

Cataract surgery

Breast surgery

Ambulatory surgery

Question 24

Active cardiac risk conditions for which patients should undergo evaluation and treatment before noncardiac surgery

Answer 24

Unstable coronary syndrome
Decompensated HF (NYHA IV, worsening or new-onset HF)
Significant arrhythmias
Severe valvular disease

Question 25

__________ is one of the strongest determinants of perioperative risk and the need for invasive monitoring.

Answer 25

Exercise tolerance

Question 26

Activities equivalent to 4 METs

Answer 26

Do light work around the house such as 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 such as scrubbing floors or lifting or moving heavy furniture?
Participate in moderate recreational activities such as golf, bowling, dancing, doubles tennis, or throwing a baseball or football?

Question 27

Factors that would warrant pharmacologic stress testing in the perioperative risk assessment that would impact decision making

Answer 27

Poor OR unknown functional capacity (<4 METs)

Question 28

Components of Revised cardiac Risk Index

Answer 28

High-risk type of surgery
History of ischemic heart disease
History of congestive HF
History of cerebrovascular disease
Preoperative treatment with insulin
Preoperative serum creatinine concentration greater than 2.0 mg/ dL.

Question 29

________ standard tool for assessing the probability of perioperative cardiac risk in a given individual and serves to direct the decision to perform cardiovascular testing and implement perioperative management protocols.

Answer 29

RCRI

Question 30

Components of Gupta perioperative myocardial infarction and cardiac arrest

Answer 30

Type of surgery
Dependent functional status
Abnormal creatinine level
American Society of Anesthesiologists class
Increasing age

Question 31

In patients with known IHD or myocardial ischemia, initiation of a titrated low-dose __________ regimen may be considered before surgery.

Answer 31

Beta blocker

Question 32

The ________ has traditionally served as an initial evaluation for the presence of CAD

Answer 32

Exercise electrocardiogram (ECG)

Patients with poor exercise capacity, in contrast, may not achieve an adequate HR and BP for diagnostic purposes on electrocardiographic stress tests

Question 33

_______ testing has became popular for many high-risk patients either cannot exercise or have limitations to exercise (e.g., patients with intermittent claudication or knee arthritis

Answer 33

Pharmacologic stress testing

Several studies have shown that the presence of a redistribution defect on dipyridamole or adenosine thallium or sestamibi imaging in patients undergoing peripheral vascular surgery predicts an increased risk for postoperative cardiac events

Question 34

Pharmacologic stress imaging is best used in patients at ___________

Answer 34

Moderate clinical risk

Question 35

Findings in stress perfusion imaging associated with higher risk

Answer 35

Larger areas of defect
Increased lung uptake
Dilation of the left ventricular cavity

Question 36

One advantage of this test is that it d cally assesses myocardial ischemia in response to increased inotropy and HR, stimuli relevant to the perioperative period.

Answer 36

Stress echocardiography

Question 37

The presence of __________ is the best predictor of increased perioperative risk, with large areas of contractile dysfunction having secondary importance.

Answer 37

New wall motion abnormalities occurring at a low HR

Question 38

In a large substudy of the _______ trial of more than 10,400 patients, higher preoperative levels of NT-proBNP associated directly with higher levels of cardiovascular events.

Answer 38

Vascular Events in Noncardiac Surgery Cohort Evaluation (VISION) trial

Question 39

____________ were traditionally c ered the time of greatest stress and risk for myocardial ischemia, but ______ may actually engender even greater risk.

Answer 39

Laryngoscopy and intubation

Extubation

Question 40

All inhalational agents have ________ and lead to decreases in myocardial oxygen demand.

Answer 40

Reversible myocardial depressant effects

Question 41

_______ offer the advantages of hemodynamic stability and lack of myocardial depression.

Answer 41

High-dose narcotic techniques

Question 42

__________ were frequently considered the “cardiac anesthesia” and were advocated for use in all high-risk patients, including those undergoing noncardiac surgery.

Answer 42

Narcotic-based anesthetics

The disadvantage of these traditional high narcotic techniques is the requirement for postoperative ventilation.

Question 43

Used for both induction and maintenance of general anesthesia; can cause profound hypotension because of reduced arterial tone with no change in HR.

Answer 43

Propofol

Question 44

Spinal or epidural techniques can produce _________, which can reduce BP and slow the HR.

_______ can also evoke reflex sympathetic activation mediated above the level of blockade, which might lead to myocardial ischemia.

Answer 44

Sympathetic blockade

Spinal anesthesia and lumbar or low thoracic epidural anesthesia

Question 45

The primary clinical difference between epidural and spinal anesthesia is the ability to ________, as opposed to a single dose with spinal anesthesia,

Answer 45

Provide continuous anesthesia or analgesia with placement of an epidural catheter

Question 46

The major issue with MAC is the ________ because the tachycardia associated with inadequate analgesia may be worse than the potential hemodynamic effects of general or regional anesthesia.

Answer 46

Ability to block the stress response adequately

Question 47

________ is the strongest predictor of perioperative ischemia.

Answer 47

Tachycardia

Question 48

In the DECREASE studies, HR control reduced the incidence of perioperative MI, with the greatest benefit achieved if HR was controlled to _______________

Answer 48

Less than 70 beats/min

Question 49

The ___________ trial demonstrated that an acute high-dose beta blockade protocol in patients naïve to beta adrenergic blockade therapy was associated with hypotension and a higher rate of stroke in the metoprolol arm

Answer 49

POISE

Question 50

Dawood and associates, as cited in the guidelines, demonstrated that fatal perioperative MI occurs predominantly in patients with ___________, but the severity of preexisting stenosis did not predict the infarct territory.

Answer 50

Multivessel coronary disease, especially left main and three-vessel disease

Question 51

Fatal events occurred primarily in patients with advanced fixed stenoses, but that the infarct may result from plaque rupture in a _____________ of the diseased vessel.

Answer 51

Mild or only moderately stenotic segment

Question 52

Epidural anesthesia may decrease ______________ compared with general anesthesia

Answer 52

Platelet aggregability

Question 53

Both vascular and nonvascular death increased similarly with increasing troponin T levels, and more than half of all deaths were from ________ causes

Answer 53

Nonvascular

Indeed, a troponin T level of 0.02 ng/mL was associated with more than a twofold risk for death. With a troponin T level of 0.3 ng/mL or higher, the hazard ratio (HR) for death increased to more than 10-fold above that in patients without any elevation in troponin

Question 54

Perioperative MImhas peak incidence on the ______ days

Answer 54

Second and third postoperative days

Traditionally, perioperative MI has been associated with 30% to 50% short-term mortality, but recent series have reported a fatality rate of less than 20% for perioperative MI.

Question 55

The finding that tachycardia, hypotension, and hypertension in the operative suite predicted release of troponin suggests a hemodynamic consequence rather than plaque rupture event (________ vs. type 1 MI).

Answer 55

Type 2

Question 56

Minimum duration of DAPT before undergoing noncardiac surgery

BMS
DES

Answer 56

BMS: >/= 30 days (Class 1 to proceed with surgery)

DES: >/= 6 months (Class 1); 3-6 months (Proceeding with surgery may be considered; delayed surgery risk is greater than stent thrombosis risk)

Question 57

ACC/AHA guidelines suggest that perioperative beta blockers can be considered on a case-by-case basis in patients with

Answer 57

Significant myocardial ischemia
Three or more RCRI risk factors
Compelling long-term indication for beta blockers

Question 58

If beta blockers are to be used, it is recommended that initiation begin _______ before surgery.

Answer 58

1 day or more

Initiation on the day of surgery has been associated with an increase in stroke and mortality. In hospital, short-acting oral or IV beta blockers should be used to permit titration to hemodynamics.

Question 59

No specific BP or HR targets have been validated, although BP control to ________ and HRs of _________ may be reasonable when beta blockers are used.

Answer 59

Less than 140/90 mm Hg

60 to 80 beats/min

Question 60

Starting _______ therapy should be considered in patients who meet ACC/AHA lipid guideline recommendations and in cardiovascular high-risk patients, because they merit this treatment even without surgery.

Answer 60

Statin

Statin use was associated with a 45% reduction in adverse events, including a 5% absolute reduction in 30-day mortality.

Statin use was a ciated with reductions in noncardiac events, including a 47% reduction in respiratory complications, 59% reduction in VTE, and 35% reduction in infectious complications. 35 The evidence suggests that statin therapy should be continued during the perioperative period.

Question 61

In the _________, Carson and colleagues randomly assigned hip fracture patients to a liberal transfusion strategy (hemoglobin threshold of 10 g/dL) or a restrictive transfusion strategy (symptoms of anemia or at physician’s discretion for hemoglobin level <8 g/dL).

A liberal transfusion strategy, compared with a restrictive strategy, did not reduce rates of death or inability to walk independently on 60-day follow-up and did not reduce in-hospital morbidity in elderly patients at high cardiovascular risk.

Answer 61

FOCUS (Transfusion Trigger Trial for Functional Outcomes in Cardiovascular Patients Undergoing Surgical Hip Fracture Repair) trial

Question 62

High risk surgical risk >5%

Answer 62

Question 63

Pre-operative assessment before non-cardiac surgery

Answer 63

Question 64

Antiplatelets in NCS

Answer 64

Question 65

Anticoagulation in NCS

Question 66

Bleeding risk according to type of non-cardiac surger

Question 67

Recommendations for management of antiplatelet therapy in patients undergoing non-cardiac surgery

Answer 67

Question 68

P2Y 12inhibitor interruption after percutaneous coronary intervention before elective non-cardiac surgery

Question 69

Recommendations for management of oral anticoagulation therapy in patients undergoing non-cardiac surgery

Answer 69

Question 70

Peri-operative management of non-vitamin K antagonist oral anticoagulant according to the periprocedural risk of bleeding.

Answer 70

Question 71

Timing of last non-vitamin K antagonist oral anticoagulant dose before elective NCS according to renal function.

Answer 71