Flashcards in Perioperative Cardiology Deck (67)
What surgeries are deemed to be low risk? <1%
Breast, dental, endocrine, eye
Asymptomatic carotid disease
Minor orthopedic surgery
Minor urological procedures
What surgeries are deemed to be moderate risk? 1-5%
Symptomatic Carotid Surgery
Peripheral arterial angioplasty
Endovascular aneurysm repair
Head and neck surgery
Major neurological or orthopedic surgery
Non major intra-thoracic surgery
What surgeries are deemed to be high risk? >5%
Major Vascular Surgery
Open lower limb revascularisation or amputation
Perforated bowel surgery
Pulmonary or Liver Transplant
What are examples of surgical risk stratification indicies to assess risk of perioperative morbidity and mortality?
The Revised Cardiac Index
Gupta Perioperative Risk or NSQUIP
How do you compare the Revised Cardiac Index Score to the NSQUIP?
Revised Cardiac Index
- added benefit of determining risk of CHB and APO
- less effective at determining risk after vascular non cardiac surgery
- overall more accurate risk calculator than RCI
- better for vascular surgery
What are the three cardiac risk markers that can be detected before surgery on non-invasive investigation?
LV dysfunction - echo or spect or mri
Myocardial Ischaemia - ECG, stress imaging
Heart Valve Abnormalities - echo
Is an ECG recommended for patients without risk factors scheduled for low risk surgery?
Is routine Echo recommended for patients scheduled for low-intermediate risk surgery?
What class recommendation is given for echo prior to high risk surgery?
What echo criteria are associated with major cardiac events post surgery?
LV systolic dysfunction
Aortic Valve Gradients
What amount of reversible ischaemia on non-invasive testing does not alter risk of peri-operative cardiac events?
For dipyridamole imaging in vascular surgery candidates, what was the associated risk of mortality in patients with normal, fixed and reversible defects?
1, 7, 9% respectively
What ischaemic heart rate threshold on dobutamine stress echo is predictive of post operative events?
<60% of age predicted maximal HR
What is the benefit of stress echocardiography in determining cardiac events post surgery?
High negative predictive value if negative
Poor positive predictive value even if positive
When is cardiac stress imaging recommended prior to high risk surgery?
More than 2 clinical risk factors
and poor functional capacity with METS <4
When should cardiac stress imaging be considered prior to high/intermediate risk surgery?
1-2 clinical risk factors
and poor functional capacity with METS <4
When is cardiac stress imaging recommended prior to lowrisk surgery?
What are clinical risk factors according to the RCI
2. Heart Failure
4. CKD Creat >170
5. DM requiring insulin
When would you consider BBlocker initiation in patients planned for high risk surgery?
2 or more clinical risk factors
ASA of 3 or more
Which BBlockers would be used first line if initiation was warranted for perioperative cardiac risk?
Bisoprolol or Atenolol
(N.B. atenolol may increased risk of stroke in one single centre study)
What surgery would you consider initiation of statin therapy prior, and what is the ideal timing of treatment?
Start 2 weeks before and continue for at least 1 month after
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?
Decreased likelihood given revascularisation.
What is the utility of BNP in perioperative care of the cardiac patient?
Post op comparison with pre-op BNP can predict death and MI post non-surgery.
What is the anaerobic threshold which is a marker of increased risk with cardiopulmonary exercise test?
< 11mL O2/kg/min
What is the benefit of routine angiography +/- stenting in patients undergoing CEA with a normal echo and ecg?
Decreased risk of myocardial infarction.
What are the steps in assessing cardiovascular risk for surgery?
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
What is the peri-operative risk of a patient with LAD or RBBB?
No different from another matched patient without the ecg findings.
When should a repeat echo be considered in stable patients who has LV dysfunction?
If no echo has been performed within a year.
When is an echo needed prior to surgery?
1. Abnormal ECG without previous workup
2. Suspicion of valvular heart disease
3. SOB or evidence of decompensated HF