Preoperative Management of
Cardiac Patients Undergoing
Noncardiac Surgery.
Prof.Dr. Rasim Enar
CTF Cardiyoloji ABD.
CVD increase with age (>65). (1) Coincidentally, this is
the same age group in which the largest number of
surgical procedures is performed. (2) Thus, it is
conceivable that the number of noncardiac procedure
performed in older persons will increase current; nearly
¼ of these major intra-abdominal, thoracic, vascular,
and orthopedic procedures that have been associated
with significant perioperative cardıovascular morbidity
and mortality.
Cardıovascular complications account for
appropximately %50 deaths in patients submitted to
major noncardiac surgery, and more than %90 of these
occurs in patients with CHD (coronary heart disease).
General Aproach to the Patient (I):
İn patients known CAD or the new onset signs or
symptoms suggestive of CAD, baseline cardiac
assesment should be performed.
1- İn the asymptomatic patient; a more extensive
assesment of history and physical examination is
warranted in those individuals age 50 years or older,
because evidenced related to the determination of
cardiac risk factors and higher cardiac risk index
occured in this population.
2- Cardiac patients with a high risk of postoperative
infarctıon and cardiac death; can be identified by
careful elucidation of the history and a physical
examinatıon, followed by ECG, chest x-, ray, and, where
needed; Holter monitoring. Echocardiogram, and
exercise stress test.
General Aproach to the Patient (II):
İn patients with CHD, it is necessary to carefully
evaluate the following parameters:
► LV (left ventricle) reserve.
► Coronary reserve or ischemic burden.
These findings and understanding of the
complicatıons that may occur in patients with
CHD, when submitted to the intensive stress of
catecholamines, hypotension, decreased
preload or hypervolemia, myocardial
depressant effect, and interactions of cardiac
medications, are vital for the formulatıon of a
ratıonal plan of management.
Pathophysıology of Cardıologıc Complicatıons
From Surgery (I):
2 important factors apear to play a major role
initiating ischemic complications:
(1) Activation sympathetic nervous system.
(2) Sensitizatıon of the ischemic myocardium to
increase catecholamines.
Pathophysıology of Cardıologıc
Complicatıons From Surgery (II):
The 12- 72 hour postoperative hypermetabolic
state, imposes considerable demands that
reguire adeguate LV fonctıon and coronary flow
reserve.
Holter monitoring, indicates an increased
incidence of painless ischemia before adverse
cardiac outcomes during the 2- 5 day
ofpostoperative period.
The advertent withdrawal of antianginal or
antihypertensive medications, may predispose
intraoperative and postoperative complications.
Also, surgical trauma promotes activation of
new platelets, which, with added stasis, are
linked to the initiation of venous
thromboemolism.
Rısk Stratificatıon and Plan of
Management :
►Mortality is clearly related to the
following:
Age over 75 years (mortalitesi 7 days but ≤ month) with evidence of
important ischemic risk by clinical symptoms or
noninvasive study.
Severe angina (CCS class –III, -IV).
Decompansated congestive HF.
Significant arrythmias.
High grade AV- block.
Symptomatic ventricular arrhytmias, in the presence of
underlying heart disease.
Supraventricular arrythmias, with uncontrolled ventricular
rate.
Severe valvular disease.
INTERMEDİATE:
Mild angina pectoris (CCS class –I or - II).
Prior MI by history or pathological Q waves.
Companseted congestive HF.
Diabetes Mellitus.
Renal insuffıciency.
MİNOR:
Advanced age.
Abnormal ECG (LVH, LBBB, ST-T abnormalities).
Rhytm other than sinus ( atrial fibrillation).
Low fonctional capacity ( e.g., inability to climb one stairs
with a bag of groceries).
History of stroke.
Uncontrolled systemic hypertension.
Active cardiac conditions for Which patient
Should Undergo Evalutıon and treatment before
Noncardiac Surgery (I):
1- Unstable coronary syndromes:
Unstable or severe angina (CCS class III or IV ).
Recent MI (more than 7 days but less than or equal 1
month).
2- Decompansated HF (NYHA functional class IV or new-
onset HF).
3- Significant arrhytmias:
High- grade AV block.
Mobitz II AV block
Third-degree AV heart block
Symptomatic ventricular arrhytmias.
Supraventricular arrhytmias ( including AF) with
uncontrolled ventrıcular rate ( at rest, HR>100 per
minute).
Symptomatic bradycardia.
Newly recognized VT.
Active cardiac conditions for Which patient
Should Undergo Evalutıon and treatment before
Noncardiac Surgery (II):
4- Severe valvular disease:
Severe aortic stenosıs ( mean pressure
gradient >40 mmHg, aortic valve area %40.
Absence of Silent ischemia or frequent multiform
ectopics on Holter EF> %40.
Peri and postoperative use of Beta- blockage if not
contraindicated.
Nitrates, commencing 6 hours perioperative and for
48- 96 hours postoperative: transdermal nitrate q 6
hours X 24- 96 hours, then wean off.
Low dose Aspirin (80 to 162.5 mg daily from day 2),
prevent fatal or nonfatal MI or thromboembolism.