Cardiac Patients Having Non-Cardiac Surgery

Question 1

Aims of preoperative cardiac management

Answer 1

• Identification of patients with potentially life-threatening cardiac disease that requires preoperative assessment and treatment by a cardiologist
• Identification of the most appropriate testing and avoidance of unnecessary testing
• Identification and implementation of most appropriate medical and interventional cardiovascular treatment and strategies

Question 2

Perioperative CV Management

Answer 2

Anesthetic perioperative management
* Choice of anesthetic drug and method
* Type of monitoring
* Postoperative care
Surgical decision making
* Postponement
* Modification
* Cancellation

Question 3

Anesthesia Questions to ask

Answer 3

• Can this patient reasonably have noncardiac surgery?
• Would coronary revascularization improve the long-term prognosis from a cardiac standpoint and protect the patient from adverse events during the necessary noncardiac surgery?

Question 4

What are classifications for anesthesia recommendations?

Answer 4

I = Benefit&raquo_space;> Risk
Procedure/Treatment SHOULD be performed/administered
IIa = Benefit&raquo_space; Risk
Additional studies with focused objectives needed
It is REASONABLE to perform procedure/administer treatment
IIb = Benefit > Risk
Additional studies with broad objectives needed
Procedure/Treatment MAY BE CONSIDERED
III = No benefit or Harm
No benefit – procedure/treatment is not helpful – no proven benefit
Harm – Excess cost w/o benefit – harmful to patient

Question 5

Levels of Evidence

Answer 5

Level A
Multiple populations evaluated
Data derived from multiple RCT or meta-analyses
Level B
Limited populations evaluated
Data derived from a single RCT or nonrandomized studies
Level C
Very limited populations evaluated
Only consensus opinion of experts, case studies, or standard of care

Question 6

Surgical Necesity

Answer 6

Emergency
Life or limb is threatened (<6 hours)
Urgent
Life or limb threatened (6-12 hours)
Time-sensitive
> 1 – 6 weeks = negatively affect outcome
Elective
May be delayed up to 1 year

Question 7

Risk of Procedure

Answer 7

Low Risk (<1%)
Breast – Dental – Endocrine – Eye – Gynecology – Plastics – Minor Orthopedic (knee) – Minor Urologic

Elevated Risk (> 1%)
Intraperitoneal – Intrathoracic – Vascular – Head and Neck – Neurological – Major Orthopedic (hip and spine) – Lung – Kidney – Liver (transplant) – Urologic major

Question 8

Clinical risk factors Coronary artery disease

Answer 8

• MACE after noncardiac surgery is associated with prior CAD events
• > 60 days after MI before noncardiac surgery in the absence of coronary intervention
• Recent MI (within 6 months), was found to be an independent risk factor for perioperative stroke
• A history of cerebral vascular disease has been shown to predict perioperative MACE

Question 9

Clinical risk factors- Heart Failure

Answer 9

Pulmonary edema – paroxysmal nocturnal dyspnea, rales or third heart sound – chest x-ray showing pulmonary vascular redistribution – orthopnea and DOE
LVEF < 30%
Diastolic dysfunction
High rate of MACE, prolonged LOS, and higher rates of postoperative HF
Natriuretic peptides

Question 10

Patients with clinically suspected moderate or greater degrees of valvular stenosis or regurgitation undergo preoperative echocardiography if ____ or ____.

Answer 10

there has been either 1) no prior echo within 1 year or 2) a significant change in clinical status or physical examination since last evaluation (LoE C)

Question 11

asymptomatic severe asymptomatic severe AS recommendations

Answer 11

Elevated-risk elective noncardiac surgery with appropriate intraoperative and postoperative hemodynamic monitoring is reasonable to perform in patients with asymptomatic severe AS

Question 12

Aortic Stenosis Anesthetic Implications

Answer 12

Hypotension and tachycardia
Decreased coronary perfusion, Development of arrhythmias or ischemia, Cardiac failure, Death
Invasive hemodynamic monitoring
Optimization of loading conditions
Percutaneous aortic balloon dilation
TAVR

Question 13

asymptomatic patients with severe MS recommendations

Answer 13

Elevated risk elective noncardiac surgery using appropriate intraoperative and postoperative hemodynamic monitoring may be reasonable in asymptomatic patients with severe MS if valve morphology is not favorable for percutaneous mitral balloon commissurotomy.

Question 14

Mitral Stenosis anesthetic implications

Answer 14

Monitor intravascular volume
Adequate forward cardiac output without excessive rises in LAP and PCWP
Avoid tachycardia and hypotension
Open mitral commissurotomy
Percutaneous mitral balloon commissurotomy

Question 15

Adults with asymptomatic and severe MR and AR recomendations

Answer 15

Elevated risk elective noncardiac surgery with appropriate intraoperative and postoperative hemodynamic monitoring is** reasonable** in adults with asymptomatic severe MR (LoE C)
Elevated risk elective noncardiac surgery with appropriate intraoperative and postoperative hemodynamic monitoring is reasonable in adults with asymptomatic severe aortic regurgitation and a normal LVEF (LoE C)

Question 16

Goals for Aortic and Mitral Regurgitation

Answer 16

LV volume overload
Optimize forward CO - Maintain preload - Avoid excessive afterload