Cardiac Assessment Flashcards by Nancy Proszek

What are MINOR predictors of increased cardiovascular peri-op risk?

Uncontrolled HTN (syst over 160, diastolic over 100)
Abnormal ECG
Rhythm other than sinus
Low functional capacity

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What are the 5 steps in cardiac assessment?

Step 1: urgency of surgery
Step 2: determine if active cardiac condition
Step 3: determine surgical risk
Step 4: assess functional capacity
Step 5: assess clinical predictors/markers

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What are INTERMEDIATE clinical predictors of increased cardiovascular peri-op risk?

CAD
Prior MI > 1 month and Q waves
Hx mild, stable angina
Compensated LV failure or CHF
DIabetes
Chronic renal insufficiency (CR > 2 mg/dL)
Cerebrovascular disease

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What are MAJOR clinical predictors of increased cardiovascular peri-op risk?

Unstable coronary syndromes
Acute or recent MI < 1 month
Unstable or severe angina
Decompensated CHF (LV failure)
Significant arrhythmias
Severe valvular disease

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The overall mortality risk of acute MI after general anesthesia is about _____%
Highest risk period within _____ days after acute MI

0.3%

30 days

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Which surgeries are considered “high risk” of having a cardiac event?

Intraperitoneal, intrathoracic, aortic surgery and other major vascular surgery, emergent major operations, prolonged procedures with large fluid shifts/ blood loss

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Which surgeries are considered “intermediate risk” of having a cardiac event?

Carotid endarterectomy, peripheral vascular surgery, head and neck, neurologic/orthopedic, and endovascular aneurysm repair

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Which surgeries are considered “low risk” for having a cardiac event?

Low risk is less than 1% risk

Endoscopic procedures, superficial, biopsies, cataract, breast surgery, GYN

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If a 12-lead ECG is indicated before surgery, how much time do you have to get it?

Must be taken within 30 days of surgery

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What are the three goals of getting a cardiac history?

Find out the severity, progression, and functional limitations

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Describe the Duke Activity Status Index

METS measures myocardial oxygen consumption (metabolic equivalents of tasks). You want your patient above 4, under 4 is high risk
1-4 METS = eating, dressing, walk in house, dishes (ADLs)
4-10 METS = climbing stairs, walk outside, heavy housework, bowl, dance, golf
Over 10 METS = strenuous sports, swimming, tennis, running

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____% of ischemic episodes in CAD patient occur without angina (silent)
_____% of acute MIs are silent

80%

10-15%

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Why does Prinzmetal angina occur?

Vasospastic angina at rest

In 85%, there is a proximal lesion in a major artery, 15% just have a spasm

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What timeframe must a pacemaker or ICD be evaluated before surgery?

3-6 months (this can be done remotely)

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What do we do with pacemakers/ICDs during surgery?

By putting a magnet over the pacemaker, it will go into asynchronous mode
Inactivate ICD tachyarrhythmia detection and put defibrillator pads on (this is NOT done by the magnet)

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Where are the 5 areas that you listen to in cardiac assessment?

Aortic: second intercostal space, R sternal border
Pulmonic: second intercostal space, L sternal border
Erb’s point: third intercostal space, L sternal border
Tricuspid: 4th/5th intercostal space, L sternal border
Mitral: 5th intercostal space, L midclavicular line

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What is the ACC/AHA recommendations concerning beta blockers?

CONTINUE beta blocker therapy
Discontinuing may increase CV morbidity
If a patient is at cardiac risk, you may want to consider giving them beta blockers, if they have never been on beta blockers, they should start 2-7 days before surgery if you want to use it (don’t start for the first time during surgery)

What signs and symptoms might you see with a heart failure patient?

Orthopnea, docturnal coughing, fatigue, peripheral edema, 3rd/4th heart sound, resting tachycardia, rales, JVD, ascites
LVH on ECG should raise suspicion

What are some diagnostics that can be done for a patient with heart failure before surgery?

ECG, Chem 7, BUN/creatinine, BNP <100 pg/ml (over 100 is bad), CXR if pulmonary edema is suspected, echo to measure LVEF
Continue all heart failure meds, if possible

Antiplatelets are discontinued _____ days before surgery (aspirin, plavix). Anticoagulants are discontinued ____ days/hours before surgery (coumadin, LMWH). Fibrinolytics usually can’t be discontinued

Antiplatelets 7-10 days
Coumadin 3-5 days
LMWH 12 hours
(You want INR less than 1.5)

What are reasons to order chest xray?

Over 75 years old
History of CHF
Symptomatic cardiovascular disease

What are 5 things to review on a 12-lead ECG?

Acute myocardial ischemia
Old MI
Rhythm/conduction disturbances
Cardiomegaly or ventricular hypertrophy
Other ECG abnormalities, electrolyte imbalances (prolonged QT hypocalcemia, short QT hypercalcemia, flat/interveted T waves hypokalemia, peaked T hyperkalemia)

What are the 5 principle indicators of acute ischemia?

ST elevation greater than/equal to 1mm
T wave inversion
Q waves develop
ST depression less than/equal to 1 mm
Peaked T waves

Which leads are associated with inferior MI? Which artery?

II, III, aVF

RCA

Which leads are associated with posterior MI? Which artery?

V1,V2,V3 | RCA

Which leads are associated with antero-septal MI? Which artery?

V1,V2,V3,V4 | LAD

Which leads are associated with lateral MI? Which artery?

I, aVL, V5,V6 | Circumflex branch of LCA

When would you do a 12 lead ECG?

Atleast 1 clinical risk factory having vascular surgery CAD PVD, CVD having intermediate or high risk surgery You don't do it on low risk surgery with someone with no risk factors Get within 30 days of surgery if you are going to do it

Why do a treadmill stress test?

This will stimulate SNS by increasing BP and HR therefore increasing myocardial O2 demand and consumption with exercise, look for ischemia in ECG changes Interpreted based on duration of exercise, max HR, time of onset of ST depression, degree of ST depression, time until resolution of ST segment

What would be a positive test of treadmill stress testing?

This would be predictive of CAD ECG criteria: ST depression > 2.5mm, ST depression in first few min of test, ventricular arrhythmias, prolong ST depression in post recovery period Non-ECG criteria: Increase in BP/HR during ST depression or if hypotension occurs (hypotension is ominous sign!)

What is a pharmacological stress test?

When someone can't do a treadmill stress test IV injection of thallium (radiopharmaceutical dye) allows imaging of blood flow in the heart Then give adenosine as a vasodilator to increase coronary blood flow and see areas of decreased perfusion (cold spots) to determine old MI/ischemia

What will an echocardiogram tell you?

``` Measures cardiac chambers and vessels and thickness of myocardium EF (ventricular systolic function) Wall motion abnormalities Valve structure and motion Blood flow and measure gradients Chamber enlargement Detects pericardial fluid ```

Why can a stress echocardiogram be useful?

It can predict adverse cardiac events that may happen during surgery (exercise/stress)

What are circumstances that you might order a preop echo?

Current or prior heart failure with worsening dyspnea or other change in status Dyspnea of unknown origin Aortic stenosis

What information can you get from a coronary angiography?

Diffuseness of obstructive disease Adequacy of angioplasties or bypass grafts CA spasms LV pressure, volume, EF (LV dysfunction) Valvular lumen area and valve gradients (degree of regurgitation, gradients across valves and shunts), PA pressures, CO and SVR

When would you have a preop catheterization?

Stable angina with left main CAD Stable angina with 3-vessel disease Stable angina with 2-vessel disease and significatn proximal LAD lesion and EF under 50 or ischemia on stress test High-risk unstable angina or non-ST elevation MI Acute ST elevation MI

How long should you wait to have surgery for a patient with a patient that had... Balloon angioplasty? Bare-metal stent? Drug-eluting stent?

Balloon angio: wait 14 days Bare metal stent: wait 30-45 days Drug eluting stent: wait over a year! Bc you don't want them to stop antiplatelet therapy, but don't want them to have excessive bleeding during surgery

Why might an MRI be used for cardiac assessment?

Assesses function and viability of the myocardium Highly sensitive in detecting infarctions using gadolinium Good at determining intracardiac tissue characterization

What are SBE (subacute bacterial endocarditis) prophylaxis guidelines (what conditions and what surgeries are they used for)?

Give high-risk patients antibiotics to prevent this. High-risk cardiac conditions: prostetic heart valves, history of infective endocarditis, unrepaired cyanotic congenital heart disease, repaired congenital heart defect with residual defects, cardiac transplantation recipients with cardiac valve disease.. For these procedures: dental procedures, invasive respiratory tract procedures. NOT for GU/GI unless they have UTI

SBE Prophylaxis drugs?

30-60 min before procedure Ampicillin 2 gm OR cefazolin 1 gm OR ceftriaxone 1 gm IV If allergic to PNC, clindamycin 600 mg IV