CV Assessment Flashcards
What is the goal of prep assessment?
The goal of preop cardiac assessment is to identify patients with heart disease who are at high risk for perioperative cardiac morbidity or mortality or those with modifiable conditions or risk.
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
Minor Clinical Predictors of Increased Cardiovascular Risk
Uncontrolled HTN
Abnormal ECG
Low functional capacity
Rhythm other than sinus rhythm
Intermediate Clinical Predictors of Increased Cardiovascular Risk
Intermediate Known CAD Prior MI > 1 month and Q waves on ECG History of mild, stable angina Compensated or previous LV failure / CHF Diabetes Chronic renal insufficiency (CR > 2.0 mg/dL) Cerebrovascular disease (stroke, TIA)
Major Clinical Predictors of Increased Cardiovascular Risk
Major (Active Cardiac Conditions) Unstable coronary syndromes Acute or recent MI < 1 month Unstable or severe angina Decompensated CHF Significant arrhythmias Severe valvular disease
Risk for Acute Perioperative Infarction
The overall mortality risk of acute MI after GA is about 0.3%
incidence is increased in the patient undergoing intra-thoracic or intra-abdominal surgery or surgery lasting longer than 3 hours
If history of prior MI
greater than 6 months ago, the incidence of perioperative myocardial reinfarction is about 6%
3-6 months ago, the incidence is 10%
within 3 months, 30%
If reinfarction occurs, the mortality rate is @ 50%
Highest risk period within 30 days after acute MI
ACC/AHA guidelines recommend waiting atleast 4-6 weeks post MI before elective surgery
Surgery-specific Risk
High risk:
Intraperitoneal, intrathoracic, aortic surgery and other major vascular surgery, emergent major operations (esp. elderly), prolonged procedures with large fluid shifts/blood loss.
Intermediate risk:
Carotid endarterectomy, peripheral vascular surgery, head and neck, neurologic/orthopedic, and endovascular aneurysm repair.
Low risk:
Endoscopic procedures, superficial, biopsies, cataract, breast surgery, GYN.
What are the basic components of a cardiac assessment overview?
History taking including medications Physical exam Resting 12-Lead ECG, if indicated within 30 days of surgery
What is the goal of obtaining a history?
Goal of history is to elicit
- severity - progression - functional limitations
What are some questions to ask?
Short of breath lying flat (orthopnea)? With exertion?
Congestive heart failure?
Heart attack? Angina (with activity/ @ rest), or chest pain/ pressure/ tightness related to your heart? What are precipitating factors?Associated symptoms
What is frequency? Duration of pain? Methods of relief
Irregular heartbeat or palpitations? Pacemaker? ICD? Heart murmur? Diagnostic tests, therapies, names of treating physician? Problems with blood pressure or HTN? PVD? TIA/CVA?
Diabetes? Renal insufficiency?
High cholesterol?Estrogen status?
Age and weight? Fatigued?
Syncope? Anemia?Smoke or drink alcohol? Illicit drug use?
Patient’s Functional Capacity
Exercise tolerance - in the absence of significant lung disease, is the most “striking” evidence of decreased cardiac reserve.
Duke Activity Status Index
1-4 METS (eating, dressing, walking around house, dishwashing)
4-10 METS (climbing stairs, walk in neighborhood, heavy housework, golf, bowl, dance)
> 10 METS (strenuous sports ie:swimming, tennis, running, football, basketball)
Those patients unable to meet a 4-MET demand are considered to be at higher risk.
Angina
Angina – sign of imbalance between myocardial oxygen supply vs. demand.
Be aware that patients with Aortic Stenosis may experience angina despite normal coronaries.
Esophageal spasm caused by heartburn can result in angina-like pain and can be relieved by NTG.
Approximately 80% of ischemic episodes in CAD patients occurs without angina. (silent)
10-15% of acute MIs are silent.
Prinzmental’s Angina
Vasospastic angina that occurs at rest.
In 85%, there is a fixed proximal lesion in a major artery. 15% have just spasm.
Patients have a higher incidence of migraine HA and Raynaud’s perhaps due to a basic vaso-spastic disease.
Pacemakers and ICD
Things to know:
The indication for insertion of the pacemaker or ICD
The underlying rhythm and rate
The type of pacemaker ( demand, fixed, or radiofrequency), the chamber paced, and the chamber sensed Have the pacemaker or defibrillator interrogated by a qualified member of CIED
Note current settings and battery life Evaluate effect of magnet
Inactivate ICD tachyarrhythmia detection and put defibrillator pads on Device should be evaluated within 3-6 months before surgery
Electromagnetic interference can occur with electrocautery, which can inhibit pacemaker firing
Have a magnet immediately available.
Most pacemakers can be converted to a fixed rate (asynchronous mode) by placing a magnet over the pacemaker box
Grounding pads should be as far from the pulse generator and leads as possible
Bipolar electrocautery is preferred; avoid monopolar
Monitor some form of blood flow (pulse oximetry, intra-arterial BP measurement)
Have external pacing available
Physical Exam
Overall appearance Obesity SOB Sternal incision, pacemaker box Heart Heart sounds Murmurs Neck JVD Carotid Bruit Lungs Lung sounds (rales) SOB, effort Vital signs (BP in both arms) Extremities Peripheral edema Pulses Clubbing Skin color
Hypertension
BP readings greater 140/90 mmHg
Major risk factor for cardiovascular mortality.
HTN increases the incidence of stroke, CHF, MI and progression to renal insufficiency and malignant hypertension
Treat HTN if SBP > 160 mmHg and diastolic BP >90 mmHg
Beta-blockers may have a protective benefit
When a patient has hypertension
If patient has long-standing severe HTN or uncontrolled HTN may need to delay surgery to control BP need ECG and serum CR/BUN If on diuretics, CHEM 7 Continue meds Antianxiolytics
