Cardiac Evaluation
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Questions and Answers

What are the six independent predictors of complications in the Cardiac Risk Index?

  • Type of surgery, history of hypertension, history of diabetes, preoperative serum creatinine, preoperative treatment with insulin, history of cerebrovascular disease
  • History of ischemic heart disease, history of hypertension, type of surgery, history of cerebrovascular disease, preoperative serum creatinine, preoperative treatment with insulin
  • History of hypertension, history of cerebrovascular disease, type of surgery, history of congestive heart failure, preoperative serum creatinine, preoperative treatment with insulin
  • Type of surgery, history of ischemic heart disease, history of congestive heart failure, history of cerebrovascular disease, preoperative treatment with insulin, preoperative serum creatinine (correct)

    • What is the most common form of end organ damage associated with hypertension?

  • Diabetes
  • Ischemic heart disease (correct)
  • Cerebrovascular disease
  • Congestive heart failure

    • How much does a systolic blood pressure increase of 20mmHg and a diastolic blood pressure increase of 10mmHg double?

  • Lifetime risk of cerebrovascular disease
  • Lifetime risk of diabetes
  • Lifetime risk of congestive heart failure
  • Lifetime risk of cardiovascular disease (correct)

    • What percentage of patients undergoing major surgery experience serious myocardial injury?

    <p>8%</p> Signup and view all the answers

    What is defined as hypertension?

    <p>&gt;140/90 mmHg</p> Signup and view all the answers

    Why is it important to have a good review of systems and questioning in clinical decision making related to cardiac issues?

    <p>To reduce the risk of perioperative cardiac events</p> Signup and view all the answers

    Which type of stent requires waiting 6 months at minimum for elective surgery?

    <p>Drug eluting stent</p> Signup and view all the answers

    What is a significant predictor of stent thrombosis?

    <p>Discontinuation of clopidogrel</p> Signup and view all the answers

    What is recommended for patients with elective surgery in the presence of acute heart failure?

    <p>Contraindicated surgery</p> Signup and view all the answers

    Which biomarker is considered a powerful marker of cardiovascular disease in nonsurgical patients?

    <p>Brain natriuretic peptide (BNP)</p> Signup and view all the answers

    What is a major cause of diastolic dysfunction in heart failure?

    <p>Increased filling pressures for abnormal relaxation</p> Signup and view all the answers

    Why is it important to assess for recent changes in clinical status before surgery in patients with heart failure?

    <p>To prevent complications by postponing surgery if needed</p> Signup and view all the answers

    What is the recommended systolic blood pressure threshold to postpone elective surgery?

    <p>200 mmHg</p> Signup and view all the answers

    Which of the following is a common risk factor for heart disease according to the text?

    <p>Male gender</p> Signup and view all the answers

    What is a characteristic of chronic stable angina?

    <p>Chest pain that is stable over 2 months</p> Signup and view all the answers

    What is a symptom of unstable angina?

    <p>Chest pain at rest</p> Signup and view all the answers

    What is the most important determinant of perioperative risk according to the text?

    <p>Exercise tolerance</p> Signup and view all the answers

    What does excellent exercise tolerance in patients with stable angina suggest?

    <p>The myocardium can be stressed</p> Signup and view all the answers

    What is the Duke Activity Status Index (DASI) used for?

    <p>Identifying patients at risk for myocardial infarction</p> Signup and view all the answers

    What is considered a 'positive' result in an Exercise EKG?

    <p>&gt;1 mm of horizontal or down-sloping ST-segment depression</p> Signup and view all the answers

    Which cardiac testing method provides information about coronary perfusion with greater sensitivity than exercise stress?

    <p>Nuclear stress testing</p> Signup and view all the answers

    What does the text mention about the diagnostic prediction of coronary plaque stability?

    <p>There is no diagnostic test to predict stability of coronary plaque.</p> Signup and view all the answers

    '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?

    <p>Almost two thirds</p> Signup and view all the answers

    Both bare metal stents and drug-eluting stents are at risk of thrombus formation.

    <p>True</p> Signup and view all the answers

    Clopidogrel discontinuation is a minor predictor of stent thrombosis.

    <p>False</p> Signup and view all the answers

    Heparin bridging is recommended for patients with stents before elective surgery.

    <p>False</p> Signup and view all the answers

    Patients with bare metal stents must wait at least 6 months before elective surgery.

    <p>False</p> Signup and view all the answers

    Diastolic dysfunction in heart failure is characterized by decreased filling pressures and abnormal relaxation.

    <p>False</p> Signup and view all the answers

    Clopidogrel discontinuation is the most significant independent predictor of stent ______

    <p>thrombosis</p> Signup and view all the answers

    Elective surgery in the face of acute heart failure is ______

    <p>contraindicated</p> Signup and view all the answers

    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

    <p>ischemia</p> Signup and view all the answers

    Patients with bare metal stents must wait ____ at minimum for elective surgery.

    <p>30 days</p> Signup and view all the answers

    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

    • Reduction of risk factors for coronary artery disease is essential

    • Lifestyle modification and pharmacologic management of angina are vital

    • 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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