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RACP Cardio AT > Perioperative Cardiology > Flashcards

Perioperative Cardiology Flashcards

1
Q

What surgeries are deemed to be low risk? <1%

A 
Superficial surgery
Breast, dental, endocrine, eye
Asymptomatic carotid disease 
Minor orthopedic surgery 
Minor urological procedures
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2
Q

What surgeries are deemed to be moderate risk? 1-5%

A 
Intraperitoneal surgery 
Cholecystectomy 
Symptomatic Carotid Surgery 
Peripheral arterial angioplasty
Endovascular aneurysm repair 
Head and neck surgery 
Major neurological or orthopedic surgery 
Renal Transplant
Non major intra-thoracic surgery
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3
Q

What surgeries are deemed to be high risk? >5%

A 
Major Vascular Surgery 
Open lower limb revascularisation or amputation
Thromboembolectomy
Duodenal/pancreatic surgery 
Oesophagectomy
Liver resection 
Perforated bowel surgery 
Adrenal resection 
Cystectomy
Pneumonectomy 
Pulmonary or Liver Transplant
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4
Q

What are examples of surgical risk stratification indicies to assess risk of perioperative morbidity and mortality?

A

The Revised Cardiac Index

Gupta Perioperative Risk or NSQUIP

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5
Q

How do you compare the Revised Cardiac Index Score to the NSQUIP?

A

Revised Cardiac Index

  • added benefit of determining risk of CHB and APO
  • less effective at determining risk after vascular non cardiac surgery

NSQUIP

  • overall more accurate risk calculator than RCI
  • better for vascular surgery
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6
Q

What are the three cardiac risk markers that can be detected before surgery on non-invasive investigation?

A

LV dysfunction - echo or spect or mri
Myocardial Ischaemia - ECG, stress imaging
Heart Valve Abnormalities - echo

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7
Q

Is an ECG recommended for patients without risk factors scheduled for low risk surgery?

A

No

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8
Q

Is routine Echo recommended for patients scheduled for low-intermediate risk surgery?

A

No

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9
Q

What class recommendation is given for echo prior to high risk surgery?

A

IIb C

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10
Q

What echo criteria are associated with major cardiac events post surgery?

A

LV systolic dysfunction
Mod-Severe MR
Aortic Valve Gradients

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11
Q

What amount of reversible ischaemia on non-invasive testing does not alter risk of peri-operative cardiac events?

A

<20%

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12
Q

For dipyridamole imaging in vascular surgery candidates, what was the associated risk of mortality in patients with normal, fixed and reversible defects?

A

1, 7, 9% respectively

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13
Q

What ischaemic heart rate threshold on dobutamine stress echo is predictive of post operative events?

A

<60% of age predicted maximal HR

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14
Q

What is the benefit of stress echocardiography in determining cardiac events post surgery?

A

High negative predictive value if negative

Poor positive predictive value even if positive

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15
Q

When is cardiac stress imaging recommended prior to high risk surgery?

A

More than 2 clinical risk factors

and poor functional capacity with METS <4

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16
Q

When should cardiac stress imaging be considered prior to high/intermediate risk surgery?

A

1-2 clinical risk factors

and poor functional capacity with METS <4

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17
Q

When is cardiac stress imaging recommended prior to lowrisk surgery?

A

Never

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18
Q

What are clinical risk factors according to the RCI

A
  1. IHD
  2. Heart Failure
  3. Stroke/TIA
  4. CKD Creat >170
  5. DM requiring insulin
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19
Q

When would you consider BBlocker initiation in patients planned for high risk surgery?

A

2 or more clinical risk factors

ASA of 3 or more

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20
Q

Which BBlockers would be used first line if initiation was warranted for perioperative cardiac risk?

A

Bisoprolol or Atenolol

N.B. atenolol may increased risk of stroke in one single centre study

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21
Q

What surgery would you consider initiation of statin therapy prior, and what is the ideal timing of treatment?

A

Vascular Surgery

Start 2 weeks before and continue for at least 1 month after

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22
Q

In a patient scheduled for non cardiac surgery who have had a CABG in the past 6 years and a normal LV EF what can be surmised about their risk of a post-op event?

A

Decreased likelihood given revascularisation.

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23
Q

What is the utility of BNP in perioperative care of the cardiac patient?

A

Post op comparison with pre-op BNP can predict death and MI post non-surgery.

ESC guidelines

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24
Q

What is the anaerobic threshold which is a marker of increased risk with cardiopulmonary exercise test?

A

< 11mL O2/kg/min

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25
Q

What is the benefit of routine angiography +/- stenting in patients undergoing CEA with a normal echo and ecg?

A

Decreased risk of myocardial infarction.

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26
Q

What are the steps in assessing cardiovascular risk for surgery?

A
  1. Risk of surgery
  2. Individual cardiac risk
  3. Is testing needed to define risk
  4. Advise patient on risk/benefit ratio of surgery
  5. Adjust medications
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27
Q

What is the peri-operative risk of a patient with LAD or RBBB?

A

No different from another matched patient without the ecg findings.

28
Q

When should a repeat echo be considered in stable patients who has LV dysfunction?

A

If no echo has been performed within a year.

29
Q

When is an echo needed prior to surgery?

A
  1. Abnormal ECG without previous workup
  2. Suspicion of valvular heart disease
  3. SOB or evidence of decompensated HF
30
Q

What is the use of Stress ECG in perioperative cardiology?

A

Establishing functional capacity when in doubt

31
Q

What is the appropriate management of a patient with stable symptoms and low risk stress test?

A

Adjust medications

Proceed with surgery

32
Q

What is the appropriate management of a patient awaiting elective surgery with class 2-3 angina and high risk stress test?

A

Postpone surgery and reassess

33
Q

What is the recommended duration of DAPT following coronary intervention with

  1. Balloon angioplasty
  2. BMS intracoronary stent
  3. DES placement
A
  1. 14 days
  2. 30 days
  3. 12 months
34
Q

When do you obtain echo in patients with valvular heart disease for a patient awaiting elective surgery

A
  1. Suspecting mod-severe valve pathology
  2. No echo in 1 year
  3. Clinical change
35
Q

What are the markers of increased pulmonary risk?

A

FEV1 <1.5 - increased pulm comp
FEV1 <1.0 - prolonged intubation
Albumin <35 - pulm comp

36
Q

What are the contraindications for surgery from the cardiac POV?

A
  1. recent MI (within 2-6 months)
  2. ACS
  3. Class 3-4 Angina
  4. Decompensated HF
  5. Mod-severe valve disease
37
Q

If someone requires surgery and has had a recent MI, what is the time frame required for delay?

A

Try to wait 60 days

38
Q

What mitral valve size in MS increases risk of perioperative outcomes?

A

<1.5cm2

39
Q

In a patient with MS (area <1.5) what additional parameter can stratify perioperative risk?

A

Pulmonary artery pressure

<50mmhg is ok

40
Q

When would you consider mitral valve commisurotomy for MS in a patient preparing for surgery?

A

Valve area <1.5
Pulmonary Artery Pressure >50

In intermediate to high risk surgery

41
Q

When does perioperative Mace increase with AR and MR?

A
  1. Symptoms

2. EF <30%

42
Q

Elective low or intermediate risk surgery can be considered in Asymptomatic patients with severe AS.

What ESC grade recommendation is this.

A

2a C

43
Q

What are the methods to minimise interference with pacemakers during surgery.

A
  1. Bipolar electrocautery
  2. Lowest possible amplitude
  3. Pacemaker set to non-sensing mode (magnet on pacemaker)
  4. Pacemaker interrogation after surgery
44
Q

How do you prevent adverse events with ICDs during surgery?

A
  1. Turn off during surgery (magnet)
  2. Turn back on in recovery phase
  3. Have external defibrillation immediately available
  4. Continuous cardiac monitoring until reactivates
45
Q

When is pre-operative carotid artery and cerebral imaging recommended?

A

History of TIA or Stroke within the past 6 months.

46
Q

What pulmonary pressures are associated with mortality in patients undergoing CABG?
What is the mortality

A

Mean >30

Mortality 7%

47
Q

What is the effect of general anaesthesia on functional MR?

A

Improvement in haemodynamics

48
Q

What is the effect of general anaesthesia on primary MR?

A

Worsening regurgitation

49
Q

How does transoesophageal Doppler guided fluid optimisation during surgery influence outcomes?

A

67% decrease in intraop mortality
25% reduction in reoperation rates
Reduced LOS

50
Q

At what thoracic dermatome would a reduction in sympathetic drive occur with spinal anaesthesia?

A

T4

51
Q

What score can be used to determine postop complication risk?

A

Apgar

  1. Lowest HR
  2. Lowest BP
  3. Blood loss
52
Q

What are the benefits of neuraxial anaesthesia compared to general anaesthesia?

A

Less AF, pneumonia, DVT, Ileus, resp depression.

53
Q

What are the risks of neuraxial anaesthesia compared to general anaesthesia?

A

Worse hypotension, urinary retention, pruritis.

54
Q

What clinical exam findings are highly associated with MACE?

A

Third heart sound

Raised JVP

55
Q

Does href or hfpef portend worse perioperative cardiovascular risk?

A

Hfref

56
Q

What are the features of mitral stenosis where non cardiac surgery can be performed safely?

A

> 1.5cm2

OR

Significant MS which is Asymptomatic with PASP <50mmhg

Otherwise consider PMC if surgery is high risk

57
Q

In those with moderate to severe AS what are the additional features that increase peri-operative risk?

A

High risk surgery
Symptoms
Mod to severe MR
Coronary artery disease

58
Q

What are the indications for AS management prior to non cardiac surgery?

A
  1. Symptoms of AS
  2. Asymptomatic with high risk Non cardiac surgery

AND

Low risk AV surgery

59
Q

In severe AR and MR what are the factors which would make non cardiac elective surgery reasonable?

A
  1. Asymptomatic patient
  2. Preserved LV systolic function

If not consider valve surgery before

60
Q

In severe AR and/or MR, at what EF would you avoid non cardiac surgery unless strictly necessary?

A

<30%

61
Q

Does Asymptomatic non sustained ventricular arrhythmia increase cardiac complications in non cardiac surgery?

A

No

62
Q

How does reversible or irreversible ischaemia on stress testing inform on timing of cardiovascular risk?

A

Reversible - risk in periop period

Irreversible - risk longer term

63
Q

What is the negative predictive value of stress testing for perioperative cardiac events?

A

90-100%

64
Q

What medication additions may be considered prior to intermediate to high risk surgery?

A

B blocker

Statin (particularly vascular sx)

65
Q

What medications are associated with harm if initiated pre operatively?

A

Alpha blockers

Aspirin - when no prior CVD history

66
Q

What type of electrocautery can potentially lead to interaction with cardiac devices?

A

Monopolar

Bipolar/harmonic scalpel - extremely unlikely to cause issues

67
Q

When would you consider non invasive stress testing preoperatively?

A
  1. When result changes management
  2. High risk surgery
  3. Poor/unknown METs
  4. Risk factors for CAD

RACP Cardio AT (13 decks)

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