Long-case Perioperative CV disease

Question 1

What are the surgical risks following ACS and how would you manage a pre-operative cardiac patient for non-cardiac surgery

AHA has developed a stepwise algorithm to help delineate who is safe for surgery or not and when to consider delaying or cancelling nor emergent surgery
This includes…..

Answer 1

The preoperative cardiac evaluation must be carefully tailored to the patient and nature of the surgical illness (e.g., acute surgical emergency vs elective)

Careful teamwork and communication between the patient, primary care physician, anesthesiologist, consultant, and surgeon

AHA guidelines

• Recency of re-vasculrisation
• Any up to date angiograms or coronary evaluation
• Symptoms
• Decompensated heart failure
• Arrhythmia
• Presence/severity of vascular disease
• Co-morbidities e.g. DM/CKD/HTN
• Riskiness of surgery
• Functional capacity

Question 2

What are the major clinical predictors of increased peri-operative CV risk

Answer 2

1. ) Acute MI < 7 days
2. ) Recent MI 7-30 days
3. ) Unstable or severe angina
4. ) Evidence of large ischaemic burden e.g. symptoms or non-invasive testing
5. ) Decompensated CCF
6. ) Significant arrhythmias - high grade AV block, SVT with uncontrolled rate, symptomatic with known underlying heart disease
7. ) Severe valvular disease

Question 3

How would you estimate functional capacity using the metabolic equivalent scale

Patients unable to meet 4 MET demand are at increased risk peri-operatively

Answer 3

1 MET

• Can you take care of yourself
• Eat, dress, wash
• Walk around indoors
• walk slowly on the flat
• Light housework like washing dishes

4 MET

• Heavy housework like moving furniture
• Climb a flight of stairs or walk up a hill
• Walk briskly
• Run a short distance
• Moderate recreation e.g. golf, dancing

10 MET
Strenuous activity