Cardiac Evaluation.pptx

Cardiac Exam and Testing Health Assessment Heart Disease in the U.S. Goals of Cardiovascular Assessment Identify risk of heart disease based on risk factors Identify presence and severity of heart disease Symptoms Physical exam Diagnostic testing Determine need for further preoperative testing Modif...

Cardiac Exam and Testing Health Assessment Heart Disease in the U.S. Goals of Cardiovascular Assessment Identify risk of heart disease based on risk factors Identify presence and severity of heart disease Symptoms Physical exam Diagnostic testing 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 CV Disease Accounts for almost 50% of all perioperative deaths Serious myocardial injury occurs in 8% of patients undergoing major surgery Some preoperative interventions modify this risk Clinical Decision Making Unfortunately, patients present with vague cardiac symptoms Sometimes, surgery is necessary and we don’t have time for a huge workup Rarely will additional workup be necessary Importance of good ROS and questioning Hypertension Defined: 2 or more BP readings of >140/90 mmHg Increases in frequency with age Duration and severity correlates with end-organ involvement Ischemic heart disease is most common for of end organ damage with HTN SBP 20mmHg, DBP 10 mmHg change  doubles lifetime risk of CV disease HTN in young people? Dig deeper, there is likely another cause Hypertension Focus is on end-organ involvement and other cardiac risk factors Testing should include EKG and renal function Elective surgery should be postponed for SBP >200 mmHg OR DBP >115 mmHg In general, patients should take their anti-hypertensive medications In general, it’s best to hold ACE-I and ARB medications (according to the textbook BUT more recent studies are suggesting to NOT hold these). You’re welcome. Clinical Predictors of CV Risk Heart Disease 30% of patients in your OR have heart disease (and it’s not diagnosed) Two biggest risk factors: Male Increasing Age Other risk factors: hypercholesterolemia, systemic hypertension, cigarette smoking, diabetes mellitus, obesity, a sedentary lifestyle, and a family history of premature development of ischemic 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, or an increase in the severity or frequency of previously stable angina without an increase in levels of cardiac biomarkers Patient history Smoker? History of chest pain, chest tightness? Trouble with your heart? Exercise tolerance (want to determine 5 METS) One of the most important determinants of perioperative risk and number one reason to elicit further testing/evaluation DOE, orthopnea? Diaphoresis? Other comorbidities? METS (Metabolic Equivalent) Exercise Tolerance 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 Associated with greater perioperative risk Increased risk of developing hypotension with ischemia Likelihood of serious adverse events inversely related to number of blocks a patient can walk Moving Beyond METS Duke Activity Status Index https://www.mdapp.co/duke-activity-status-index-dasi-c alculator-546/ 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 Cardiac Testing 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. MI or Angina Treatment of Coronary Disease Identification and treatment of diseases that can precipitate or worsen ischemia Reduction of risk factors for coronary artery disease Lifestyle modification Pharmacologic management of angina Revascularization by coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) with or without placement of intracoronary stents. PCI and Stents Two main types of stents Bare metal Drug eluding BOTH are at risk of thrombus formation BOTH will be placed on antiplatelet therapy Clopidogrel discontinuation is the most significant independent predictor of stent thrombosis (14 times) The longer you wait to stop, the better Heparin “bridging” is NOT recommended, can be detrimental Stents Bare metal MUST WAIT 30 DAYS at minimum for elective surgery Consider duel antiplatelet therapy Drug eluding MUST WAIT 6 months at minimum for elective surgery BMS: bare metal stent DES: drug eluding stent DAPT: dual antiplatelet therapy Perioperative MI Preoperative Predictors of MI Preoperative Predictors of MI Heart Failure Elective surgery in the face of acute heart failure is contraindicated Systolic dysfunction Decreased EF and abnormal contractility Ischemia is major cause Diastolic dysfunction (50% of cases of heart failure) Increased filling pressures for abnormal relaxation Normal contractility and ejection HTN is major cause Goal is to identify and minimize effects of failure Heart sounds Heart failure classification (more next week) Heart Failure Brain natriuretic peptide (BNP) Released form atria and ventricles in response to ischemia or strain Useful in evaluating decompensated heart failure Powerful marker of CV disease in nonsurgical patients In non-cardiac surgery, BNP helps predict risk Useful in screening when activity level cannot be assessed EKG, BUN, Creatinine, and BNP are indicated in heart failure Guidelines suggest echo to assess Dyspnea of unknown origin Recent changes in clinical status Surgery should be postponed in decompensated or untreated failure Focused Preop Cardiac Assessment Focused questions History of an MI? When Treatment (CABG v. PCI v. Medical) History of heart failure? History of chest pain, tightness? Try to elicit symptoms Determine exercise tolerance Presence of other co-morbidities Focused Cardiac Assessment Auscultation of the heart (neck) and lungs Reviewing any cardiac testing If it was ordered, YOU HAVE to get the results