Preoperative Cardiac Workup Flashcards
What upper limit of blood pressure would cause you to reschedule a patient for an elective procedure and why?
Diastolic pressure greater than 110 mmHg because the patient is at risk for end-organ damage.
If a patient’s elective procedure was cancelled in order to get their hypertension “under control,” how long should it be under control before having the procedure?
Blood pressure should be under control for at least two weeks before the procedure. (No solid evidence to support this just merely current thinking).
According to the ACC/AHA guidelines regarding Peri-Operative Cardiac Evaluation for a Non-Cardiac Surgery, what conditions mandate intensive management and may result in delay or cancellation of non-emergent surgery?
Unstable or severe angina Recent MI Significant arrythmias Severe valvular disease Decompensated heart failure
What are the revised Goldman clinical risk predictors for major cardiac complications?
High-risk surgery Ischemic heart disease Congestive heart failure Cerebral vascular disease IDDM Creatinine higher than 2 mg/dL (CRI)
What are the minor clinical risk predictors in the current ACC/AHA guidelines regarding Peri-Operative Cardiac Evaluation for a Non-Cardiac Surgery?
Age greater than 70 years old
Abnormal ECG (e.g., LVH, LBBB, ST-T abnormalities)
Abnormal rhythm
Uncontrolled systemic hypertension
What are the non-cardiac surgical procedures considered high-risk for cardiac events?
Aortic and other major vascular surgery
Peripheral vascular surgery
Emergency Surgery
Anticipated long procedures w/ associated fluid shifts and large EBL
What are the non-cardiac surgical procedures considered intermediate-risk for cardiac events?
Intraperitoneal and intrathoracic surgery CEA Head and neck surgery Orthopedic surgery Prostate surgery
What are the non-cardiac surgical procedures considered low-risk for cardiac events?
Endoscopic procedures Superficial procedures Cataract surgery Breast Surgery Ambulatory surgery
What are the clinical risk predictors consistent with ischemic heart disease
History of MI History of positive treadmill test Use of NTG Current c/o CP thought to be 2/2 coronary ischemia ECG w/ Q waves
What are the clinical risk predictors consistent with congestive heart failure?
h/o CHF pulmonary edema paroxysmal nocturnal dyspnea peripheral edema bilateral rales S3 heart sound Chest radiograph w/ pulm vascular redistribution
What are the clinical risk predictors consistent with cerebral vascular disease?
h/o TIA
h/o stroke
What is the reported cardiac risk in terms of percentage of a high-risk non-cardiac procedure?
Often reported as more than 5%
What is the reported cardiac risk in terms of percentage of an intermediate-risk non-cardiac procedure?
1 - 5%
What is the reported cardiac risk in terms of percentage of an low-risk non-cardiac procedure?
< 1%
What are the recommendations regarding preoperative resting ECG for non-cardiac surgery?
Class 1: patients with at least 1 clinical risk factor undergoing vascular surgical procedures
- Patients w/ known CAD, PAD, CVD undergoing intermediate-risk procedures.
Class 2a - no clinical risk factors but are undergoing vascular surgery procedures
Class 2b - at least one clinical risk factor undergoing intermediate-risk operative procedures
In what patients is an ECG not indicated prior to surgery?
Not indicated in asymptomatic persons without clinical risk factors undergoing low-risk surgical procedures.
What are the ACC/AHA recommendations regarding preoperative non-invasive stress testing before non-cardiac surgery?
Class 1: Pts w/ active cardiac conditions
Class 2a: Pts w/ 3 or more clinical risk factors and poor functional capacity who require vascular surgery IF IT WILL CHANGE MANAGEMENT
Class 2B: a) 1 - 2 clinical risk factors and poor functional capacity who require intermediate risk non cardiac surgery IF IT WILL CHANGE MANAGEMENT
b) Consider for patients with 1 - 2 risk factors and good functional capacity undergoing vascular surgery IF IT WILL CHANGE MANAGEMENT
Who, according to the ACC/AHA recommendations, should not get preop non-invasive stress testing before non-cardiac surgery?
Patients with no clinical risk factors undergoing intermediate-risk surgery.
Nor patients undergoing low-risk non-cardiac surgery.
What are the ACC/AHA recommendations regarding coronary revascularization with CABG of PCI before non-cardiac surgery?
Class 1: pts:
- stable angina w/ significant left main coronary artery stenosis
- stable angina with three-vessel disease
- stable angina with two vessel disease with significant proximal left anterior descending stenosis and either an EF < 0.5 or demonstrable ischemia on non-invasive testing
- high-risk unstable angina or non-ST-segment elevation MI
- acute ST-elevation MI
CLASS 2A: In patients who require coronary revascularization for mitigation of cardiac symptoms and will need an elective surgery within the next 12 months. A balloon angioplasty or a bare-metal stent followed by 4 - 6 weeks of dual-anti-platelet therapy is probably indicated.
If a patient has recently received a DES and needs urgent surgery, how should their medications be altered?
It is reasonable to continued ASA if at all possible and restart the thienopyridine therapy as soon as possible.
How long should a patient wait to have elective non-cardiac surgery after bare-metal stent placement? DES? Balloon angioplasty?
4 - 6 weeks of bare-metal coronary stent
1 year for DES
4 weeks for balloon angioplasty
What are the ACC/AHA recommendations regarding beta-blockers before non-cardiac surgery?
Continue in patients already receiving beta-blockers for angina, symptomatic arrhythmias, hypertension, etc…
Start in patient undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preop testing.
Probably should start in patients undergoing high-risk surgery with more than one risk factor.
NEVER GIVE TO ANYONE WITH ABSOLUTE CONTRAINDICATION TO BETABLOCKADE
What are the ACC/AHA recommendations regarding statins before non-cardiac surgery?
Continue if currently taking statins
Statin use is reasonable for patients undergoing vascular surgery with or without clinical risk factors.
