Preoperative Cardiac Workup

Question 1

What upper limit of blood pressure would cause you to reschedule a patient for an elective procedure and why?

Answer 1

Diastolic pressure greater than 110 mmHg because the patient is at risk for end-organ damage.

Question 2

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?

Answer 2

Blood pressure should be under control for at least two weeks before the procedure. (No solid evidence to support this just merely current thinking).

Question 3

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?

Answer 3

Unstable or severe angina
Recent MI
Significant arrythmias
Severe valvular disease
Decompensated heart failure

Question 4

What are the revised Goldman clinical risk predictors for major cardiac complications?

Answer 4

High-risk surgery
Ischemic heart disease
Congestive heart failure
Cerebral vascular disease
IDDM
Creatinine higher than 2 mg/dL (CRI)

Question 5

What are the minor clinical risk predictors in the current ACC/AHA guidelines regarding Peri-Operative Cardiac Evaluation for a Non-Cardiac Surgery?

Answer 5

Age greater than 70 years old
Abnormal ECG (e.g., LVH, LBBB, ST-T abnormalities)
Abnormal rhythm
Uncontrolled systemic hypertension

Question 6

What are the non-cardiac surgical procedures considered high-risk for cardiac events?

Answer 6

Aortic and other major vascular surgery
Peripheral vascular surgery
Emergency Surgery
Anticipated long procedures w/ associated fluid shifts and large EBL

Question 7

What are the non-cardiac surgical procedures considered intermediate-risk for cardiac events?

Answer 7

Intraperitoneal and intrathoracic surgery
CEA
Head and neck surgery
Orthopedic surgery
Prostate surgery

Question 8

What are the non-cardiac surgical procedures considered low-risk for cardiac events?

Answer 8

Endoscopic procedures
Superficial procedures
Cataract surgery
Breast Surgery
Ambulatory surgery

Question 9

What are the clinical risk predictors consistent with ischemic heart disease

Answer 9

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

Question 10

What are the clinical risk predictors consistent with congestive heart failure?

Answer 10

h/o CHF
pulmonary edema
paroxysmal nocturnal dyspnea
peripheral edema
bilateral rales
S3 heart sound
Chest radiograph w/ pulm vascular redistribution

Question 11

What are the clinical risk predictors consistent with cerebral vascular disease?

Answer 11

h/o TIA

h/o stroke

Question 12

What is the reported cardiac risk in terms of percentage of a high-risk non-cardiac procedure?

Answer 12

Often reported as more than 5%

Question 13

What is the reported cardiac risk in terms of percentage of an intermediate-risk non-cardiac procedure?

Answer 13

1 - 5%

Question 14

What is the reported cardiac risk in terms of percentage of an low-risk non-cardiac procedure?

Answer 14

< 1%

Question 15

What are the recommendations regarding preoperative resting ECG for non-cardiac surgery?

Answer 15

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

Question 16

In what patients is an ECG not indicated prior to surgery?

Answer 16

Not indicated in asymptomatic persons without clinical risk factors undergoing low-risk surgical procedures.

Question 17

What are the ACC/AHA recommendations regarding preoperative non-invasive stress testing before non-cardiac surgery?

Answer 17

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

Question 18

Who, according to the ACC/AHA recommendations, should not get preop non-invasive stress testing before non-cardiac surgery?

Answer 18

Patients with no clinical risk factors undergoing intermediate-risk surgery.
Nor patients undergoing low-risk non-cardiac surgery.

Question 19

What are the ACC/AHA recommendations regarding coronary revascularization with CABG of PCI before non-cardiac surgery?

Answer 19

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.

Question 20

If a patient has recently received a DES and needs urgent surgery, how should their medications be altered?

Answer 20

It is reasonable to continued ASA if at all possible and restart the thienopyridine therapy as soon as possible.

Question 21

How long should a patient wait to have elective non-cardiac surgery after bare-metal stent placement? DES? Balloon angioplasty?

Answer 21

4 - 6 weeks of bare-metal coronary stent
1 year for DES
4 weeks for balloon angioplasty

Question 22

What are the ACC/AHA recommendations regarding beta-blockers before non-cardiac surgery?

Answer 22

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

Question 23

What are the ACC/AHA recommendations regarding statins before non-cardiac surgery?

Answer 23

Continue if currently taking statins

Statin use is reasonable for patients undergoing vascular surgery with or without clinical risk factors.