Non-Cardiac Surgery for Cardiac Patients 2024

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Questions and Answers

Which surgical procedures are considered high risk for cardiac complications?

Orthopedic surgery

Vascular surgery (correct)

Cataract surgery

Endoscopic procedures

Which cardiac conditions should be identified pre-operatively?

Diabetes

Unstable coronary syndromes (correct)

Allergy to anesthesia

Hypertension

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?

70-80% Signup and view all the answers

What cardiac condition can be assessed by an echocardiogram?

Cardiac ejection fraction and regional wall motion abnormalities Signup and view all the answers

When should a patient undergo non-invasive stress testing before non-cardiac surgery?

If they have active cardiac conditions Signup and view all the answers

What should be done regarding anti-platelet therapy in patients undergoing non-cardiac surgery after stent placement?

Continue DAPT unless bleeding risk outweighs benefits Signup and view all the answers

Coronary angiography is recommended prior to non-cardiac surgery without specific clinical indications.

False Signup and view all the answers

The presence of abnormal Q-waves on pre-operative ECG in high-risk patients indicates increased _________ risk.

peri-operative Signup and view all the answers

Which medication therapy may be started in patients at high risk of myocardial ischemia noted in pre-operative assessments?

Beta-blockers Signup and view all the answers

What does MACE stand for?

Major adverse cardiac events Signup and view all the answers

What is the ASA PS class for a normal healthy patient?

ASA PS class 1 Signup and view all the answers

Advanced age is independently associated with an increased risk of major adverse cardiac events.

True Signup and view all the answers

Which of the following are independent predictors of complications in the Revised Cardiac Risk Index (RCRI)? (Select all that apply)

History of ischemic heart disease Signup and view all the answers

What is associated with an increased perioperative risk?

Symptomatic coronary disease Signup and view all the answers

Which biomarker is significantly associated with MACE in vascular patients within 30 days of surgery?

BNP Signup and view all the answers

The presence of __________ in a pre-operative setting should prompt an investigation into underlying cardiopulmonary disease.

arrhythmia Signup and view all the answers

After a myocardial infarction, patients should wait 12 months before undergoing surgery.

False Signup and view all the answers

What is the recommended action for patients with severe aortic stenosis undergoing elective non-cardiac surgery?

Monitor hemodynamic status intra-operatively and post-operatively Signup and view all the answers

Match the cardiac risk factors with their corresponding RCRI Risk Assessment level:

Ischemic heart disease = Low (0 factor) Congestive heart failure = Low (1 factor) Cerebrovascular disease = Intermediate (2 factors) Diabetes mellitus treated with insulin = High (3 or more factors) Signup and view all the answers

What is considered a high-risk type of surgery?

Intraperitoneal, intrathoracic, or suprainguinal vascular surgery Signup and view all the answers

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.