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Questions and Answers
What are the six independent predictors of complications in the Cardiac Risk Index?
What is the most common form of end organ damage associated with hypertension?
How much does a systolic blood pressure increase of 20mmHg and a diastolic blood pressure increase of 10mmHg double?
What percentage of patients undergoing major surgery experience serious myocardial injury?
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What is defined as hypertension?
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Why is it important to have a good review of systems and questioning in clinical decision making related to cardiac issues?
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Which type of stent requires waiting 6 months at minimum for elective surgery?
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What is a significant predictor of stent thrombosis?
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What is recommended for patients with elective surgery in the presence of acute heart failure?
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Which biomarker is considered a powerful marker of cardiovascular disease in nonsurgical patients?
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What is a major cause of diastolic dysfunction in heart failure?
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Why is it important to assess for recent changes in clinical status before surgery in patients with heart failure?
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What is the recommended systolic blood pressure threshold to postpone elective surgery?
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Which of the following is a common risk factor for heart disease according to the text?
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What is a characteristic of chronic stable angina?
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What is a symptom of unstable angina?
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What is the most important determinant of perioperative risk according to the text?
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What does excellent exercise tolerance in patients with stable angina suggest?
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What is the Duke Activity Status Index (DASI) used for?
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What is considered a 'positive' result in an Exercise EKG?
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Which cardiac testing method provides information about coronary perfusion with greater sensitivity than exercise stress?
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What does the text mention about the diagnostic prediction of coronary plaque stability?
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'New-onset angina pectoris or a change in angina pattern' is described by what percentage of patients before an acute MI according to the text?
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Both bare metal stents and drug-eluting stents are at risk of thrombus formation.
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Clopidogrel discontinuation is a minor predictor of stent thrombosis.
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Heparin bridging is recommended for patients with stents before elective surgery.
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Patients with bare metal stents must wait at least 6 months before elective surgery.
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Diastolic dysfunction in heart failure is characterized by decreased filling pressures and abnormal relaxation.
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Clopidogrel discontinuation is the most significant independent predictor of stent ______
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Elective surgery in the face of acute heart failure is ______
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Brain natriuretic peptide (BNP) is a powerful marker of CV disease in nonsurgical patients and is released from atria and ventricles in response to ______ or strain
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Patients with bare metal stents must wait ____ at minimum for elective surgery.
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Study Notes
Cardiovascular Assessment
- Goals of cardiovascular assessment:
- Identify risk of heart disease based on risk factors
- Identify presence and severity of heart disease
- Determine need for further preoperative testing
- Modify the risk of perioperative cardiac events
Cardiac Risk Index
- Six independent predictors of complications:
- High-risk type of surgery
- History of ischemic heart disease
- History of congestive heart failure
- History of cerebrovascular disease
- Preoperative treatment with insulin
- Preoperative serum creatinine >2.0 mg/dL
Hypertension
- Defined: 2 or more BP readings of >140/90 mmHg
- Increases in frequency with age
- Duration and severity correlate with end-organ involvement
- Ischemic heart disease is the most common form of end-organ damage with hypertension
- SBP 20mmHg, DBP 10 mmHg change → doubles lifetime risk of CV disease
- HTN in young people? Dig deeper, there is likely another cause
Clinical Predictors of CV Risk
- 30% of patients in the OR have heart disease (and it’s not diagnosed)
- Two biggest risk factors: Male and Increasing Age
- Other risk factors:
- Hypercholesterolemia
- Systemic hypertension
- Cigarette smoking
- Diabetes mellitus
- Obesity
- Sedentary lifestyle
- Family history of premature development of ischemic heart disease
Symptoms of Heart Disease
- Symptoms usually only develop after demand exceeds supply
- Chronic stable angina:
- Chest pain that does not change appreciably in frequency or severity over 2 months or longer
- Unstable angina:
- Angina at rest
- Angina of new onset
- Increase in the severity or frequency of previously stable angina without an increase in levels of cardiac biomarkers
METS (Metabolic Equivalent)
- Exercise tolerance is one of the most important determinants of perioperative risk
- Excellent exercise tolerance, even in patients with stable angina, suggests the myocardium can be stressed
- Dyspnea with chest pain during minimal exertion raises the probability of extensive CAD
- Increased risk of developing hypotension with ischemia
- Likelihood of serious adverse events inversely related to number of blocks a patient can walk
Duke Activity Status Index (DASI)
- Helps to identify patients at risk for:
- Myocardial injury
- Myocardial infarction
- Moderate-to-severe complications
- New disability
- Some data suggest DASI is moderately correlated with LV function
- Surrogate for echo when LV function is the goal
Cardiac Testing
- 12 lead EKG:
- 30% of MIs occur without symptoms
- No longer “age based”
- Males over 65
- Anyone with a positive history
- Those that you suspect to be at risk
- Exercise EKG:
- Tries to induce ischemia if present
- “Positive” if >1 mm of horizontal or down-sloping ST-segment depression during or within 4 minutes after exercise
- Nuclear stress testing:
- Looks at coronary perfusion; greater sensitivity than exercise stress
- Useful in those that cannot exercise
- Stress Echo
- Stress MRI
- Calcium CT
- Cardiac Cath:
- Best information about condition of the coronaries
Cardiac Evaluation Algorithm
-
Coronary Plaque:
- There is NO DIAGNOSTIC test that can predict stability of coronary plaque
- Best you will get is information about amount of plaque
- You have no idea when it will rupture
-
Almost two thirds of patients describe new-onset angina pectoris or a change in their angina pattern during the 30 days preceding an acute MI.### Coronary Disease Treatment
-
Identification and treatment of diseases that can precipitate or worsen ischemia are crucial
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Reduction of risk factors for coronary artery disease is essential
-
Lifestyle modification and pharmacologic management of angina are vital
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Revascularization by coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) with or without placement of intracoronary stents is a treatment option
PCI and Stents
- There are two main types of stents: bare metal and drug-eluting
- Both types of stents are at risk of thrombus formation and require antiplatelet therapy
- Clopidogrel discontinuation is the most significant independent predictor of stent thrombosis (14 times)
- The longer the wait to stop antiplatelet therapy, the better
- Heparin "bridging" is not recommended and can be detrimental
Stent-Specific Guidelines
- Bare metal stents: must wait at least 30 days for elective surgery, consider dual antiplatelet therapy
- Drug-eluting stents: must wait at least 6 months for elective surgery
Perioperative MI and Heart Failure
- Heart failure is a contraindication for elective surgery in acute cases
- Preoperative predictors of MI include heart failure, systolic dysfunction, and decreased EF
- Ischemia is a major cause of heart failure, while diastolic dysfunction is caused by increased filling pressures and abnormal relaxation
- Hypertension is a major cause of diastolic dysfunction
Heart Failure Evaluation
- Brain natriuretic peptide (BNP) is released in response to ischemia or strain and is a useful marker for decompensated heart failure
- BNP is a powerful marker of CV disease in nonsurgical patients and helps predict risk in non-cardiac surgery
- EKG, BUN, Creatinine, and BNP are indicated in heart failure, with guidelines suggesting echo to assess
- Surgery should be postponed in decompensated or untreated heart failure
Focused Preoperative Cardiac Assessment
- Focused questions should include history of MI
- A thorough assessment is necessary to identify and minimize the effects of heart failure
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