Chapter 42 - Cardiac complications

Question 1

Classification of post-op cardiac events

Answer 1

1) Acute coronary syndrome: unstable angina, acute MI, sudden death 2) CHF 3) myocardial injury 4) life-threatening arrhythmias

Question 2

Definition of MI

Answer 2

1) rise in cardiac troponin above 99th percentile of upper reference 2) signs/symptoms of MI: - chest pain - ST changes, LBBB - Q waves - loss of viable myocardium, new LV motion abnormalities

Question 3

Proportion of MI that are STEMI vs NSTEMI

Answer 3

30/70 favor NSTEMI used to be 50/50

Question 4

Type 1 MI

Answer 4

plaque rupture and thrombosis urgent treatment

Question 5

Early mortality with STEMI

Answer 5

10%

Question 6

NSTEMI pathologic difference

Answer 6

Partial mural ischemia Smaller territory also supplied by collateral

Question 7

Treatment for STEMI and NSTEMI

Answer 7

STEMI - urgent coronary intervention PCI NSTEMI - med first, if hemodynamic worsen or progression of symptom then PCI

Question 8

Type 2 MI

Answer 8

imbalance between myocardial oxygen supply and demand usually NSTEMI

Question 9

Triggers for type 2 MI

Answer 9

1) prolonged tachycardia 2) hypotension/hypertension 3) anemia 4) emotional or physical stress

Question 10

Rate of post-op MI in vascular surgery

Answer 10

24% troponitis 1% for STEMI

Question 11

Subtypes of CHF

Answer 11

1) heart failure with reduced EF (HFrEF) = systolic heart failure: dilated due to MI, cardiomyopathy 2) heart failure with normal/preserved EF (HFpEF) = diastolic heart failure: prolonged hypertension, LVH, female> male 3) right ventricular failure: secondary to LV failure or lung disease (cor pulmonale)

Question 12

TACO

Answer 12

Transfusion-associated cardiac overload

Question 13

Life-threatening arrhythmias

Answer 13

1) ventricular tachycardia 2) ventricular fibrillation 3) high degree AV block

Question 14

Type 3 MI

Answer 14

Sudden cardiac death

Question 15

Cardiac morbidity and all cause mortality after open aortic, bypass, carotid and EVAR

Answer 15

Cardiac morbidity OPEN aorta: 2.9-14.8% EVAR: 1.3-2.9% Bypass 3.4-10.1% (higher in CLTI) Carotid 2.3-3.4% Mortality OPEN aorta: 2.5-6.2% EVAR 0.5-2.1% carotid 0.3%

Question 16

RCRI associations

Answer 16

0 - 0.4% 1 - 0.9% 2 - 7% > 3 - 11%

Question 17

RCRI score and VSGNE CRI score

Answer 17

TABLE 42.4

Question 18

RCRI sen and spe

Answer 18

70% 55% not adequate

Question 19

VSGNE CRI score correlation with cardiac event

Answer 19

0-3 - 3.1% 4 - 5% 5 - 6.8% >6 - 11.6% better than RCRI

Question 20

BNP level and association

Answer 20

< 30 - 0.11 likelyhood ratio of cardiac event 30-116 - 3.6 > 116 - 6.4

Question 21

Coronary artery prophylaxis (CARP) trial

Answer 21

1) 510 patients for major vascular surgery 2) 1+ coronary vessels > 70% stenosis randomized to PCI/cabg vs straight to vascular surgery 3) no difference in survival to 2.5 years CABG did better than PCI ones that had ischemia on MPI did better with revasc first

Question 22

ACC/AHA statement on pre-op cardiac cath

Answer 22

1) do it if revasc is indicated 2) do not routinely revasc coronary only for purpose of reducing perioperative events

Question 23

POISE trial on beta blocker use

Answer 23

benefit of non-fatal MI with beta blocker is at the expense of stroke and 30% more all-cause mortality

Question 24

POISE-2 RCT

Answer 24

1) 10010 noncardiac surgery patients (5% had vascular) 2) ASA increased major bleed but did not improve death or MI)

Question 25

ACE trial

Answer 25

Aspirin in carotid endarterectomy 1) ASA before CEA 2) ASA 81-325 lowered stroke, MI, death

Question 26

ACC/AHA guideline on DAPT

Answer 26

1) elective surgery delay 30 d after BMS and 6 mth after DES (3 month minimum) 2) plavix if stopped must be restarted asap post-op and ASA continues

Question 27

Algorithm for perioperative MI

Answer 27

FIGURE 42.3