Cardiac

Question 1

What are the exceptions for delaying urgent/emergent surgery?

Answer 1

Active ACS
Decompensated HF
Unstable Arrhythmia

Question 2

If a patient needs to undergo emergent surgery, what are the CCS recommendations for post-operative cardiac monitoring?

Answer 2

If the patient is > 65 OR 18-64 with major CVD, then:

• Post-Op troponin daily x 48-72 hrs
• PACU ECG
• “Shared Care Management”

Question 3

What are the factors associated with major/significant CVD?

Answer 3

• Known CAD
• Cerebrovascular Disease
• PAD
• CHF
• Severe Pulmonary HTN
• Intracardiac Obstruction
• Severe Aortic/Mitral Stenosis
• HCOM

Question 4

What are the reasons you would delay urgent or semi-urgent surgery for pre-op testing?

Answer 4

Consider pre-op testing only if you suspect:

(1) Sever obstructive cardiac condition (AS)
(2) Severe pulmonary HTN
(3) Unstable cardiac condition, such as ACS or arrhythmia

Question 5

What are the per-operative cardiac recommendations for elective surgery?

Answer 5

Calculate RCRI score to assess the risk of MACE:
IF the patient is > or = 65 or RCRI > or = 1 or 45-64 with major CVD THEN
Measure BNP
IF BNP > 300 or not available, THEN
Post-op cardiac assessment with PACU ECG and daily troponins recommended.

Question 6

What are the 6 components of the RCRI score?

Answer 6

(1) High Risk Surgery (Intrperitoneal, introthoracic, suprainguinal vascular)
(2) Ischemic Heart Disease
(3) CHF History
(4) Hx of Stroke or TIA
(5) Diabetes on Insulin
(6) Pre-op creatinine > 177 mol/L

Question 7

What qualifies as ischemic heart disease in the RCRI score (5)?

Answer 7

(1) + stress test
(2) Q’s on ECG
(3) Angina
(4) Nitrate Use
(5) Hx of MI

*NOTE: If patient has had revascularization with PCI or CABG they DO NOT get a point in absence of above (ie. need to be asymptomatic)

Question 8

What qualifies as a “hx of CHF” in the RCRI score (5)?

Answer 8

(1) Pulmonary Edema
(2) PND
(3) Bilateral Crackles
(4) S3 Gallop
(5) Vascular Redistribution on CXR

Question 9

What is the risk of MACE for each RCRI score?

Answer 9

0 - 4%
1 - 6%
2 - 10%
3 or More - 15%

Question 10

When would you consider pre-operative cardiac testing in CAD?

Answer 10

For patients with unstable CAD or high risk features on non-invasive testing done in workup of symptoms.

Question 11

What are the high risk features on non-invasive stress testing that would prompt peri operative testing (6)?

Answer 11

(1) > or = 2 mm ST depression
(2) ANY ST elevation
(3) VT/VF
(4) sBP not greater than 120 mmHg or decrease by > 10 mmHg
(5) EF < 35%
(6) Stress induced LV dysfunction - EF < 45% or with decreased stress 10% +

Question 12

What do post-op troponins predict?

Answer 12

30 day mortality

Question 13

What are the Class I indications for aortic valve repair?

Answer 13

(1) Symptomatic Severe AS
(2) Asymptomatic Severe AS w/LVEF <50
(3) Asymptomatic severe AS who are undergoing cardiac surgery for other indications.
(4) Symptomatic patients w/low flow, low gradient severe AS with reduced LVEF
(5) Symptomatic patients w/low-flow low gradient with normal LVEF if AS is felt to be the most likely cause of symptoms.