Questions and Answers
Which surgical procedures are considered high risk for cardiac complications?
Which cardiac conditions should be identified pre-operatively?
Routine pre-operative cardiovascular testing is useful for asymptomatic patients undergoing low-risk surgical procedures.
False
What is the sensitivity range of the exercise ECG stress test for detecting CAD?
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What cardiac condition can be assessed by an echocardiogram?
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When should a patient undergo non-invasive stress testing before non-cardiac surgery?
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What should be done regarding anti-platelet therapy in patients undergoing non-cardiac surgery after stent placement?
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Coronary angiography is recommended prior to non-cardiac surgery without specific clinical indications.
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The presence of abnormal Q-waves on pre-operative ECG in high-risk patients indicates increased _________ risk.
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Which medication therapy may be started in patients at high risk of myocardial ischemia noted in pre-operative assessments?
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What does MACE stand for?
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What is the ASA PS class for a normal healthy patient?
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Advanced age is independently associated with an increased risk of major adverse cardiac events.
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Which of the following are independent predictors of complications in the Revised Cardiac Risk Index (RCRI)? (Select all that apply)
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What is associated with an increased perioperative risk?
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Which biomarker is significantly associated with MACE in vascular patients within 30 days of surgery?
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The presence of __________ in a pre-operative setting should prompt an investigation into underlying cardiopulmonary disease.
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After a myocardial infarction, patients should wait 12 months before undergoing surgery.
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What is the recommended action for patients with severe aortic stenosis undergoing elective non-cardiac surgery?
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Match the cardiac risk factors with their corresponding RCRI Risk Assessment level:
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What is considered a high-risk type of surgery?
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Study Notes
Terminology
- MACE refers to Major Adverse Cardiac Events, including death and myocardial infarction (MI).
- Co-morbidities that increase MACE risk include cardiovascular disease, diabetes, cerebrovascular disease, and advanced age.
Pre-operative Evaluation
- Prioritize identifying clinical risk factors and performing cardiac testing.
- Main goals:
- Define risk and need for further testing.
- Assess the necessity of peri-operative β-blockade or interventional therapy.
- Create an appropriate anesthetic plan.
Physical Status Classification
- ASA PS class 1: Normal healthy patient.
- ASA PS class 2: Mild/moderate systemic disease without functional limitation.
- ASA PS class 3: Severe systemic disease with functional limitation (e.g., stable angina).
- ASA PS class 4: Life-threatening end-stage systemic disease (e.g., congestive heart failure).
- ASA PS class 5: Moribund patient with little survival chance (e.g., ruptured aortic aneurysm).
- ASA PS class 6: Brain-dead patient for organ donation.
Revised Cardiac Risk Index (RCRI)
- RCRI provides a validated method for assessing perioperative risk using common clinical variables.
- Independent predictors of complications include:
- High-risk surgery.
- History of ischemic heart disease.
- History of congestive heart failure.
- History of cerebrovascular disease.
- Preoperative insulin treatment.
- Serum creatinine levels >2 mg/dL.
Laboratory Values
- Biomarkers like BNP and N-terminal BNP correlate with MACE risk in vascular surgery patients.
Defining Cardiovascular Risk Factors
- Symptomatic coronary disease: Unstable angina poses high perioperative MI risk.
- Congestive heart failure: Major morbidity risk factor characterized by dyspnea and peripheral edema.
- Ejection fraction: LVEF < 30% significantly raises adverse outcomes risk.
Arrhythmias and Valvular Heart Disease
- Supraventricular and ventricular arrhythmias indicate potential cardiac complications.
- Moderate to severe valvular disease may necessitate pre-operative echocardiography and possibly interventions before surgery.
Adults with Prior Myocardial Infarction (MI)
- Previous MI usually indicates underlying coronary artery disease (CAD).
- Individual risk evaluations based on recent coronary procedures (e.g., CABG).
Atherosclerotic Cardiac Disease Risk Factors
- Peripheral artery disease: Associated with silent MI and ischemia.
- Diabetes mellitus: Accelerates atherosclerosis; insulin-treated patients have increased risk.
- Hypertension: Elevated BP correlates with myocardial infarction risk; treatment of high BP may reduce long-term MI risk.
Atherosclerotic Cardiac Disease and Metabolic Syndrome
- Metabolic syndrome encompasses high BP, dyslipidemia, high fasting glucose, and central obesity, increasing perioperative risks.
- Tobacco increases CAD risk but does not independently elevate cardiac surgical risk.
Pulmonary Vascular Disease
- Patients with pulmonary hypertension should continue therapy unless contraindicated.
- Pre-operative evaluations by specialists can reduce perioperative risks.
Exercise Tolerance
- Strong predictor of peri-operative risk; poor exercise tolerance indicates higher complication likelihood.
- Good exercise tolerance minimizes need for further testing.
Indications for Further Cardiac Testing
- Decision for further testing is not always necessary; utilize clinical history and specific risks instead.
- Urgency of surgery influences pre-operative cardiac assessment requirements.
Cardiac Testing: ECG
- Pre-operative ECG is crucial for patients with known CAD or structural heart disease.
- Abnormal Q waves on ECG in high-risk patients indicate increased peri-operative risk.
Non-invasive Cardiovascular Testing
- Exercise ECG stress test effectively assesses CAD and ischemia.
- Pharmacologic stress testing is reserved for high-risk patients unable to exercise or with significant comorbidities.
Ventricular and Valvular Function
- Echocardiography assesses regional wall motion, valvular function, and is recommended for patients with dyspnea of unknown origin or worsening heart failure.
- Routine LV function assessment is not recommended; echocardiography is mandated for significant valvular disease.
Coronary Angiography
- Offers detailed coronary anatomy but is not routinely recommended before non-cardiac surgeries without specific indications.
- Sophisticated imaging techniques may assist in evaluating heart function when physical capacity is unclear.
2014 ACC/AHA Guidelines Key Points
- Identify clinical needs and active cardiac conditions before non-cardiac surgery.
- Evaluate cardiac risk based on functional capacity and specific clinical risk factors.
- Avoid unnecessary pre-operative cardiovascular testing if results won’t alter management strategies.### Coronary Artery Bypass Grafting (CABG)
- Low risk of subsequent non-cardiac surgery for CABG survivors.
- Indications for CABG prior to non-cardiac surgery remain consistent with other contexts.
Revascularization
- Recommended before high-risk non-cardiac surgeries to enhance long-term survival.
- Routine revascularization solely to minimize peri-operative cardiac events is not advised.
Percutaneous Transluminal Coronary Angioplasty
- 2014 ACC/AHA guidelines recommend angioplasty for high-risk coronary cases: unstable angina, recent myocardial infarction, or severe arrhythmias.
Coronary Artery Stents
- Early surgery post-stent placement increases risk of adverse cardiac events and peri-operative complications.
- Guidelines suggest delaying elective non-cardiac surgery: 14 days after angioplasty, 30 days after bare metal stent placement, and ideally 12 months for drug-eluting stents, though 6 months may be considered based on risk assessment.
Anti-platelet Therapy Management
- Dual anti-platelet therapy (aspirin and clopidogrel) is standard post-stent placement.
- A thienopyridine (like clopidogrel) should continue for 1 month post-bare metal stent and 12 months post-drug-eluting stent.
- Decisions about anti-platelet therapy must involve the surgical team and assess risks of bleeding versus stent thrombosis.
- Anesthesia considerations include weighing general versus regional anesthesia risks regarding anti-platelet therapy.
Cardiovascular Implantable Electronic Devices
- Pre-operative evaluations must address management of pacemakers and implantable defibrillators, as they can be affected by electromagnetic interference during surgery.
- Involvement of a cardiologist is crucial for device programming before and after surgery.
Peri-operative Beta-Blocker Therapy
- Continuation of beta-blockers is recommended for patients with chronic use.
- Initiating beta-blocker therapy may be beneficial for patients at intermediate or high myocardial ischemia risk.
- Must start beta-blocker therapy sufficiently in advance (ideally more than one day) to assess safety.
Peri-operative Statin Therapy
- Continuing statin therapy is advised for patients already on statins scheduled for non-cardiac surgery.
- New initiation of statins should be considered for patients undergoing vascular surgeries or those with specific clinical indications.
Other Peri-operative Cardiac Therapies
- Alpha-2 agonists are not recommended for patients undergoing non-cardiac surgeries.
- Limited evidence exists for calcium channel blockers; those with negative ionotropic effects may worsen heart failure in patients with decreased ejection fraction.
- Continuing ACE inhibitors or ARBs is generally acceptable; they can be restarted post-operatively if held before surgery.
Anti-platelet Agents
- Continue dual anti-platelet therapy (DAPT) in the first 4-6 weeks after stent placements unless bleeding risk is significantly high.
- During surgeries requiring the cessation of platelet inhibitors, continuing aspirin is recommended.
- For patients undergoing elective non-cardiac surgery who lack prior coronary stenting, initiating aspirin may not yield benefits unless cardiac event risk outweighs bleeding risk.
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Description
This quiz focuses on the considerations and terminology related to non-cardiac surgery for patients with cardiovascular conditions. It covers the evaluation of risk factors for major adverse cardiac events (MACE) and emphasizes the importance of clinical history and co-morbidities. Prepare to test your knowledge on pre-operative evaluations and risk management strategies.
