Cardiac Flashcards
RCRI
History of ischaemic heart disease 1
History of congestive heart failure 1
History of cerebrovascular disease 1
Use of insulin therapy for
diabetes 1
Preoperative serum creatinine >177 micromoles/L 1
High-risk surgery 1
Oxford
Risk for major CARDIAC complications
0 0.4%
1 1%
2 7%
3 11%
Who needs periop 12-lead ECG?
- pt > 65 yo
- intermediate risk surgery
- risk factors of IHD
Oxford
What are the 5 types of MI? %?
- acute atherothrombotic coronary event (25%)
- heterogeneous - imbalance of O2 supply and demand (75%)
- SCD unexpected
- ~ PCI
- ~ cardiac death
Oxford
Pharm therapy to reduce MACE risk
- Continue long term beta blocker (dec myocardial O2 demand)
- No - initial of bb 24h prior surgery
- Continue PRN nitrate
- Continue CCB - restart ASAP post op
- ACE/ARB - do not protect against MACE (But improve MI and LV dysfx survival)
- Statin - improve ST and LT outcome post non-cardiac and CABG (ESA/CCS)
Oxford
AMI
- myocardial cell death
- due to prolonged ischaemia
clinical evidence + cTNT
1+ ischaemic feature
(1. sx 2. new ECG changes 3. new RWMA 4. new cor thrombus)
cTNT
- rise 3-4h post injury
- up for 10-14d
- need 1 level >99th percentile required for dx
MINS
- definition
- incidence
- dx
- surveillance
- med mx
- Px relevant
- Myocardial injury
- Due to ischaemia
- 30d after non-cardiac sx
- pt w or w/o MI
- 20% of patients having non-cardiac surgery
- > 90% MINS - no signs/sx of ischaemia
- 20% meet MI definition
dx
1. cTNT >65ng/L
2. <30d non-cardiac Sx
3. Not due to non-ischaemic cause (e.g. AF, sepsis)
4. Not nec - sx/ECG changes
daily TnT levels on D1,2,3
- LD aspirin + statin
- ACE-i if HTN
- Anticoag (maybe) (MANAGE trial)
- ?cor angio and revasc
HF criteria
by 1. sx 2. LVEF 3. BNP/NT-proBNP 4. left heart enlargement/diastolic dysfx
<40% HFrEF
40-49% HFmrEF
50%+ HFpEF
HF mx
- delay sx progression
- optimise sx mx/FRC
- reduce mortality
HF treatment
2023b Outline the treatment strategies for chronic heart failure. pr75%
*best evidence for HFrEF
- Sacubitril/ABR OR ACEi / ARB
- b-blocker (caution with new/decom HF)
- MRA -
- Digoxin
a) AF in sx HF
b) SR in sev HF - Anticoag - HF/VTE
- No CCB
HFpEF *no reduction in morb/mort
- Diuretics
- Spiro
- bb and ACEi
Oxf Anaes
ACC/AHA
Stages
A - treat HTN
B - ACEi/ARB +/- BB
C/D - ACEi/ARB + BB + Diuretics +/- Dig +/- hydralazine/nitrate
CRT (25% pt with mod-sev HF HAS LBBB)
pacing LV and RV
- DCM EF <35%
- QRS > 120ms
- poor fx status despite max med rx
Oxf AT P.39
2023b Evaluate the use of each of the following for preoperative cardiac risk stratification: plasma biomarkers (chose ONE of natriuretic peptides OR troponin)
Duke Activity Status Index (DASI) stair-climbing test,
cardiopulmonary exercise testing (CPX/CPET).
pr65%
- Plasma biomarker
BNP
Pros - High NPV for periop cardiac events
- Predictor of death/non-fatal MI at 30/180 days
Cons
1. Optimal threshold not established
2. Cost
e14 aha/acc 2024
- DASI
MET 1 = VO2 3.5mL/kg/min
METS 4 = 14mL/kg/min
Pros:
a) simple
b)
Cons:
a) bias
- CPEX
vital, non-invasive assessment technique used to evaluate the cardiopulmonary system during rest and exercise
measure functional capacity, which is crucial for predicting postoperative outcomes, particularly for patients undergoing major surgery.
Pros:
1) non-invasive
2) functional capacity
3) risk strat
4)
cons
1) complex
2) pt limitation
3) resource intensive
2021a Standard 12-lead electrocardiogram (ECG) of a 56-year-old man in the post-anaesthesia care unit (PACU) two hours after an emergency laparotomy for bowel obstruction (ischemic changes). He is complaining of shortness of breath, abdominal pain and has a blood pressure of 160/110mmHg.
He has a history of hypertension controlled with atenolol and hydrochlorothiazide.
No preop to compare to.
Interpret this ECG and outline the appropriate management of this patient in PACU.
Pass rate 66.8%
2022b A patient presenting for surgery has a DDDR pacemaker. a) Explain the NASPE/BPEG Generic (NBG) pacemaker classification system. b) Describe the assessment and preoperative management of this DDDR device. *NASPE/BPEG - North American Society of Pacing and Electrophysiology/British Pacing and Electrophysiology Group. Pass rate 73.3%
2021a A patient presents on the day of surgery with a blood pressure of 180/110mmHg. Justify your decision to proceed with or postpone surgery for this patient.
Pass rate 25.5% (go ahead with the surgery!)
> 140/90
Expert opinion: Postponement of elective surgery in patients with arterial pressure exceeding 180mmHg systolic and/or 110mmHg diastolic.
BUT
Periop control more important
- HTN pt inc CVS lability
- post op hypo/hyper inc risk of MINS/CVE
- low threshold of IAL - aim within 20% baseline
- should be controlled prior to major surgery
*Surgical factors
Pt factors
* 2* causes of HTN
- anxiety/pain/distress
- Preop reading - unlikely accurate representation of long-term BP control
- Do not defer based on single reading on admission –> ambulatory or GP for baseline
- W/H ACEi/ARB 24h prior if controlled
- Continue bb / CCB / HCTZ
Oxf Anaes P.116
2021a
A 77-year-old patient is admitted to hospital with a fractured neck of femur requiring total hip arthroplasty. Physical examination on admission reveals signs of congestive cardiac failure.
Outline how congestive cardiac failure influences the perioperative risk for this patient. (30%)
Discuss how the finding of congestive cardiac failure influences your perioperative management of this patient. (70%)
Pass rate 84.2%
congestive cardiac failure is an independent risk factor for mortality
- NHYA Class 4 is associated with ~ 67% peri-operative mortality in non-cardiac surgery
assessment of the severity and the cause of the congestive cardiac failure
timing of surgery must be balanced against optimisation of the patient
- Urgent surgery (e.g. hip #) warrants a pre-operative risk assessment (e.g. with RCRI) if the Hx/Ex suggest potential undx severe obstructive intracardiac abnormality, severe pHTN, or unstable CV condition (e.g. unstable angina, acute stroke)
Best practice is to perform hip # ORIF within 48 (ideally < 24h)
CCS
[20B01]
You are asked to assess and anaesthetise a 54-year-old patient for a laparoscopic cholecystectomy. They received a heart transplant ten years ago. Discuss the issues relevant for this patient. (also15B02)
The denervated heart and the altered response to anaesthesia and certain drugs required discussion, as did immune suppression and Ax of the pt’s current functional status.
Sometimes omitted from answers, but of significant importance, was the issue of the pneumoperitoneum required for this procedure and how that may compromise this patient.
**25% will have surgery w/I 2 years of transplant **
- Changes in physiology post-transplant:
- Denervation ® no sensory, SNS or PNS innervation, delayed sympathetic response to circulating catecholamines
- Higher resting HR ® 90-110bpm 2’ vagal denervation
- Preload dependent cardiac output ® no SNS mediated BRR
- ECG ® 2 p waves, AF/AFL and RBBB common
- Dysrhythmias & conduction abnormalities ® PPM in 5%
- Silent ischaemia ® most common cause of death beyond 1st year (50% have atheroma on angiography by 5 years)
- Changes in pharmacologic effect of cardiac drugs:
- Immunosuppression
- HTN/nephrotox/BM supp/hepatotx - Comorbidity
- Steroids - req stress dose
- Allograft fx
IMMUNOSUPPRESSION
1) calcineurin inh - cyclo/tacro
2) purine syn inh - azathioprine/MMF
3) T-cell dependent
CTAM
