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General Approach
Team Work Patient Primary care physician Anesthesiologist Surgeon Medical consultant
O.R.
Coronary angiography
Poor (<4METs)
Noninvasive Low risk testing High risk Consider coronary angiography Subsequent care dictated by findings and treatment results
O.R.
Intermediate clinical predictors Mild angina pectoris Prior MI Compensated or prior CHF DM
Minor clinical predictors Advanced age Abnormal ECG Rhythm other than sinus Low functional capacity History of stroke Uncontrolled systemic hypertension
Major
Unstable coronary syndromes Recent myocardial infarction with evidence of important ischemic risk by clinical symptoms or noninvasive study Unstable or severe angina(Canadian Cardiovascular Society Class III or IV) Decompensated CHF Significant arrhythmias High grade atrioventricular block Symptomatic ventricular arrhythmias in the presence of underlying heart disease Supraventricular arrhythmias with uncontrolled ventricular rate Severe valvular disease
Intermediate
Mild angina pectoris(Canadian Cardiovascular Society Class I or II) Prior myocardial infarction by history or pathological waves Compensated or prior CHF DM
Minor
Advanced age Abnormal EKG(LVH, LBBB, ST-T abnormalities) Rhythm other than sinus(eg, atrial fibrillation) Low functional capacity(eg, unstable to climb one flight or stairs with a bag of groceries) History of stroke Uncontrolled systemic hypertension
4 METs
4 METs
>10 METs
Climb a flight of stairs or walk up a hill Walk on level ground at 4 mph or 6.4 km/h? Run a short distance? Do heavy work around the house like scrubbing floors or moving heavy furniture? Participate in moderate recreational activities like golf, bowling, dancing, doubles tennis, or throwing a baseball or football? Participate in strenuous sports like swimming, singles tennis, football, basket ball, or skiing
Intermediate
(Reported cardiac risk generally <5%) Carotid endarterectomy Head and neck Intraperitoneal and intrathoracic Orthopedic Prostatic
Low
(reported cardiac risk generally <1%) Endoscopic procedures Superficial procedures Cataract Breast
Combind incidence of cardiac death and nonfatal myocardial infarction Further preoperative cardiac testing is not generally required.
General Approach
The medication profile often provides good in formation about the patients condition
Physical Exam
Perform a thorough physical exam with a focu s on airway, respiratory and cardiac systems Look for MAJOR patient risk factors: CHF: (crackles, S3, JVP, edema) M Valve disease (murmurs) M
Investigations
Labs K from diuretic m Na from CHF m Cr from CRF m glucose (DM) m troponin M Hb to rule out as cause of ischemia
Investigations
Chest X-Ray (CXR)
Signs of CHF: M hilar fullness vascular redistribution Kerley B lines alveolar infiltrates (pulmonary edema) pleural effusions
Investigations
ECG
Acute MI M
Old MI m
Dysrhythmias M ventricular, 2nd or 3rd degree blocks, SVT
Echocardiography
Look for:
Valvular disease M
Coronary Angiography
Indications for Coronary Angiography in Perioperative Evaluation Before (or After) Noncardiac Surgery Class I:Patients with suspected or proven CAD High-risk results during noninvasive testing Angina pectoris unresponsive to adequate medical therapy Most patient with unstable angina pectoris Nondiagnostic or equivocal noninvasive test in a highrisk noncardiac surgical procedure
Class I: conditions for which there is evidence for and/or general agreement that a procedure or a treatment is of benefit
Indications for Coronary Angiography in Perioperative Evaluation Before (or After) Noncardiac Surgery Class II: Intermediate-risk results during noninvasive testing Nondiagnostic or equivocal noninvasive test in a lower-risk patients undergoing a high-risk noncardiac surgical procedure Urgent noncardiac surgery in a patient convalescing from acute MI Perioperative MI
Class II: conditions for which there is a divergence of evidence and/or opinion about the treatment
Indications for Coronary Angiography in Perioperative Evaluation Before (or After) Noncardiac Surgery Class III:
Low-risk noncardiac surgery in a patient with known CAD and low-risk results on noninvasive testing Screening for CAD without appropriate noninvasive testing Asymptomatic after coronary revascularization, with excellent exercise capacity(>7METs) Mild stable angina in patients with good LV function, low-risk noninvasive test results Patient is not a candidate for coronary revascularization because of concomitant medical illness Prior technically adequate normal coronary angiogram within previous 5years Severe LV dysfunction(e.g., EF<20%) and patient not considered candidate for revascularization procedure Patient unwilling to consider coronary revascularization procedure
Class III: conditions for which there is evidence and/or general agreement that the procedure is not necessary
Cardiovascular
Routine ECG men over 40 and women ov
er 55. Full eval if symptomatic Med levels(digitalis) preop Take hypertensive and cardiac meds preop. No MAO or guanethidine 2 weeks prior to s urgery
Hypertension
Anesthetic agents vasodilate
Hypervolemia, hypoventilation,pain, meds,
Arrythmias
Cardiac dz,hypoxia, hypotension, acid/base/
electrolyte Supraventricular tachy adenosine, verapa mil, propanolol, diltiazem Afib/flutter Digoxin Ventricular tach- lidocaine Cardiology consult
blockers, or nitrates before surgery, continue them into the operative and post-op period. The same is true for therapies used to control CHF Beta-blockers reduce postoperative ischemia,
Protection against ischemia may also reduce risk of MI
Anesthetic Considerations
Anesthetic agent No one best myocardial protective anesthetic technique. Opioid:cardiovascular stability, but need postoperative ventilation Inhalational agent: myocardial depression Neuraxial block: sympathetic blockade
low level:minimal hemodynamic change abdominal operation: profound effects(hypotension, reflex tachycardia)
Anesthetic Considerations
Perioperative pain management PCA(iv or epidural) leads to a reduction in postoperative catecholamine surges and hypercoagulability, both of which can theoretically impact myocardial ischemia.
Anesthetic Considerations
Intraoperative nitroglycerine Helpful or harmful
vasodilating properties of NTG with anesthetics can cause significant hypotension and even myocardial ischemia.
Transesophageal echocardiography Guidelines for the use of TEE to diagnosis or guide therapy are being developed by ASA
Perioperative Surveillance
Pulmonary artery catheters
recent MI complicated by CHF significant CAD with procedures assoc. with significant hemodynamic stress. Systolic or diastolic LV dysfunction cardiomyopathy
Perioperative Surveillance
Intraoperative and postoperative ST
monitoring
Intraoperative and postoperative ST changes are strong predictors of perioperative MI in patients at high risk who undergo noncardiac surgery proper use of computerized ST-segment analysis may improve sensitivity for detection of myocardial ischemia
Perioperative Surveillance
Surveillance for perioperative MI Clinical symptoms Postoperative ECG changes CK-MB, troponin-I, troponin-T, CK-MB isoforms
In patients with known or suspected CAD undergoing high risk procedures, obtaining ECG at baseline, immediately after the procedure, and for the first 2 postoperative days appears to be cost effective Use of cardiac enzymes is best reserved for patients with clinical, ECG, or hemodynamic evidence of cardiovascular dysfunction.
assessment and management of modifiable risk factors for CAD, heart failure, HBP, stroke, and other cardiovascular diseases. Assessment for hypercholesterolemia, smoking, hypertension, DM, physical inactivity, peripheral vascular disease, cardiac murmur(s), arrhythmias, perioperativeischemia, and MI may lead to evaluation and treatments that reduce future cardiovascular risk