Pre-op Cardiac Risk

Question 1

An increased risk of surgical cardiac complications can be seen in pts with: (3)

Answer 1

• PAD
• previous stroke
• if emergent/urgent surgery performed

Question 2

Pts with this level of cardiac risk rq. referal to cardiologist for cardiac clearance for surgery:

Answer 2

> intermediate or high cardiac risk

Question 3

Further 24-hour ambulatory testing should be done in these pts:

Answer 3

• HX syncope

- significant bradycardia or tachycardia

Question 4

Further echo testing should be done in these pts: 2

Answer 4

• evaluate valves in pts with a murmur
• evaluate LVEF in pts with HF or dyspnea of unknown cause
• -> both ass. with worst outcomes (post-op HF) with surgery

Question 5

Further exercise or pharm stress testing should be done in these pts:

Answer 5

if patient not up to date on recommended screenings per guidelines and hx of CVD

Question 6

Potential meds that can be used for a pharmacologic stress test: 4

Answer 6

• adenosine
• dipyridamole
• selective A2A receptor agonist: apadenoson, binodenoson, or regadenson
• dobutamine

Question 7

Indications for a pharmacologic stress test: 3

Answer 7

• can not exercise
• LBBB
• pacemaker or paced rhythm

Question 8

what are the stress testing modalities: 3

Answer 8

1- MPI (Radionuclide stress myocardial perfusion imaging)
—preferred method with pharm agent over exercise
—rq. SPECT agent MC technetium-99m based (Tc-99m sestamibi and Tc-99m tetrofosmin)
2- TTE (transthoracic echo)
3- CMR (stress CV MRI)

Question 9

compare and contrast the stress testing modalities:

Answer 9

• TTE has higher specificity for CAD
• MPI has higher sensitivity than others
• overall all with similar dx accuracy

Question 10

What are the revised Goldman cardiac risk index (RCRI) 6 independent predictors of major cardiac complications?

Answer 10

• HX of ischemic heart disease (previous MI, positive exercise test, angina sxs considered 2/2 decreased perfusion, nitrate tx, ECG with pathological Q waves)
• High risk surgery type of surgery (vascular, open abdominal)
• HF
• CVD
• DM rq tx insulin
• Pre-op serum creatinine > 2.0mg/dL

Question 11

what does the RCRI predict?

Answer 11

Rates of cardiac death, nonfatal MI, or nonfatal arrest
0 factors-0.4%
1- 1.0%
2- 2.4%
3 or more- 5.4%

Question 12

Cardiac event risk stratification: High risk surgeries (4)

Answer 12

> 5% risk with:

• Aortic and other major vascular surgery
• Peripheral vascular surgery
• Anticipated prolonged surgical procedures with large fluid shifts or blood loss
• Emergent major operations (esp elderly)

Question 13

Cardiac event risk stratification: low risk surgeries (4)

Answer 13

<1% risk:

• Endoscopic procedures
• Superficial procedures
• Breast surgery
• Cataract surgery

Question 14

Cardiac event risk stratification: intermediate risk surgeries (5)

Answer 14

> 1 to <5% risk:

• Intraperitoneal and intrathoracic surgery
• Carotid endarterectomy surgery
• Head and neck surgery
• Prostate surgery
• Orthopedic surgery