Periop CV evaluation Flashcards
what are considered “active cardiac conditions” for preop?
ACS
Decompensated CHF
Significant Valvular dz
Significant arrhythmias
High risk surgeries; what is the % cardiac risk?
Vascular; > 5%
Intermediate risk surgeries and % cardiac risk
CEA Intraperitoneal/intrathoracic head and neck orthopedic prostate 1-5% risk
Low risk surgeries and % cardiac risk
breast
endoscopic
cataract
<1%
examples of 4 METS
light housework (wash dishes)
flight of stairs/walk uphill
walk on level ground at 4mph
how many METS is strenuous sports like singles tenis, skiing, football)?
10 METS
What are the 5 risk factors for patients undergoing noncardiac surgery?
h/o MI or Q waves DM renal insufficiency h/o cerebrovascular dz h/o CHF
what is the only heart sound that does not increase on inspiration?
pulmonic ejection click
5 categories in Revised Cardiac Index
- high risk Sx (intraperitoneal/intrathoracic/suprainguinal vasc)
- ischemic heart dz
- cerebrovasc dz
- Cr > 2
- CHF
what is your risk of major cardiac event w/ surgery and Revised Cardiac Risk Index of 0,1,2,3 points (class I, II, III, IV)?
0 and 1 are < 1%
2 - 6.6 %
3- 11%
2 Class I indications for preop ECG
- vasc Sx and 1 or more clinical risk factors
- intermediate Sx + known CHD, PAD or cerebrovasc dz
Class I indicatios for periop assessment of LV fxn
none
what stress test is Class I indication for LBBB?
pharmacologic nuclear
high risk features on imaging stress test
EF 2segments WMA at low dose dobuta (<120
If pt is preop Vasc Sx and has 3 or more cardiac risk factors, what to do?
Stress test if it will change management
What do you do for a pt going to low risk Sx
Always send to OR (unless active cardiac condition)
According to periop cardiac risk assessment table from mayo interventional review,when is the only time you send pt to stress test preop?
3 or more risk factors with unknown fxn capacity having vascular Sx.
according to DECREASE V study, what was the difference in 30d and 1yr MI/death in high risk pt’s with significant CAD undergoing vasc sx b/w OMT or PCI?
no difference
besides ACS, what are the 3 Class I indications for pre-op revascularization?
- stable angina with sig LM stenosis
- stable angina with 3VD
- stable angina and 2VD, pLAD, AND EF < 50% or +stress test (ischemia)
what to do for a pt who just had a DES and needs urgent Sx?
hold plavix, cont. ASA if possible. restart plavix ASAP.
3 factors that reduce LV volume and make HOCM worse
hemorrhage
decreased SVR
increased venous capacitance
2 drug classes to avoid in HOCM
diuretics
beta agonists
in general, do you delay elective surgery for symptomatic/severe valvular stenosis or regurgitation?
stenosis
algorithm for pt w/ AS that needs Sx
mild/mod –> OR
Sev: sxs- AVR before OR
no sxs- make sure echo within past yr
mortality risk in pt’s w/ severe AS going to OR w/o AVR
10%
what class of meds to avoid in AR (esp. prior to Sx)?
BB
is bridging with heparin needed preoperatively for bileafleat mech AVR and no other thromboembolic risk factors?
no
risk factors for thromboembolism preoperatively?
afib previous thromboembolism LV dysfxn hypercoagulable older prosthetic valve mech. TV > 1 mech valve
which prosthetic valves have a high risk of thrombosis?
any mech MVR
mech AVR w/ a risk factor
if A/C for prosthetic valve needs to be reversed, what is preferred method?
FFP (not Vit K)
what type of electrosurgery causes electromagnetic interferon with a PPM/ICD?
monopolar (minimize bursts to <5sec)
when should you re-program a PPM to asynchronous mode for a Sx?
Sx above the umbilicus
PPM dependent patients
for pt’s undergoing elective surgery; what are the guidelines for when PPM and ICD should have been interrogated?
PPM- within 1 yr
ICD- within 6 mo
when do you have to inactivate an ICD preop?
mono polar electrosurgery or RF ablation above umbilicus
will a magnet placed over ICD force asynchronous pacing?
no
what do you for a pt. that is PPM dependent with an ICD going for supra-umbilical Sx?
reprogram it (magnet will not cause asynchronous pacing, it will just deactivate ICD arrhythmia detection)
when is it OK to give a BB for preop vasc Sx?
+ischemia on stress
or
2+ risk factors
5 q’s to ask for preop eval
- what is the procedure?
- Sx elective or emergent
- any active cardiac conditions
- what is pt’s functional capacity
- will test change anything?
According to POISE, what is the lesson for BB preop?
Don’t use them routinely preop and if you have to, start well in advance of Sx with careful titration.
Always continue for pt’s already on BB
Which OHT pt’s need abx ppx?
ones with valvular regurgitation
Class III rec for abx ppx
Solely to prevent endocarditis if undergoing GU, GI procedures (incld EGD, colonoscopy)
What med to avoid intraop for severe AS and HTN?
NTG
What rec do you give for pt intraop with severe AS and low BP/low SVR?
Poorly tolerated, give phenylephrine
When is it appropriate to do stress nuclear preop?
Intermediate Sx with 1 or more risk factors AND poor functional capacity
