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Preoperative Cardiac Exam Final - EMarcus

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Preoperative Cardiac Exam Final - EMarcus Powered By Docstoc
					Preoperative Cardiac
       Exam

      Edward Marcus
     Surgery Team IV
         7/22/08
                      Outline

   Definitions
   Perioperative Cardiac Events
   Risks of Anesthesia
   Risks of Surgery
   Classifying heart disease and surgery
   Organizing into risk categories
                           Definitions
 Perioperative                Cardiac Outcomes
    Ischemic Events
    Congestive Heart Failure

    Ventricular Tachycardia




Mangano, DT. Association of perioperative myocardial ischemia with cardiac morbidity
and mortality in men undergoing noncardiac surgery. The Study of Perioperative
Ischemia Research Group. N Engl J Med. 1990 Dec 27;323(26):1781-8.
               Ischemic Events
   Cardiac Death
   Non-Fatal MI
   Unstable Angina
     Chest pain > 30 mins unresponsive to standard
      interventions
     Transient ST+T wave changes w/o Q waves
     No enzyme elevations
     Greater than or equal to 0.1mV ST depression
      during exercise
                       Mangano et al. 1990
        Congestive Heart Failure
   Left or Right ventricular faliure
   Cardiomegaly
   Jugular venous distension
   Peripheral edema
   S3


                        Mangano et al. 1990
     Ventricular Tachycardia
5 or more consecutive beats of
 ventricular origin at 100 or more beats
 per minute



               Mangano et al. 1990
               Events observed
   15/474 (3.2%) had ischemic events
   30/474 (6.4%) had congestive heart failure
   38/474 (8%) had ventricular tachycardia
     Events occurring after the 3rd postoperative day
 half of all ischemic events
 half of congestive heart failure
 30% of ventricular tachycardia
                    Mangano et al. 1990
               Unheralded MI
   50-70% of MI’s perioperatively are painless
   Compare with only 20-40% in non-surgical
    patients




                    Mangano et al. 1990
    Why is there perioperative risk?
   Major hemodynamic stress
   Changes in cholinergic activity
   Changes in catecholamine activity
   Body temperature fluctuations
   Pulmonary function
   Fluid shifts
   Pain
                    Mangano et al. 1990
                 Risks of anesthesia
   Decreased systemic vascular resistance
   Decreased stroke volume
   Induction of general anesthesia lowers
    systemic arterial pressures by 20-30%,
    tracheal intubation increases the blood
    pressure by 20-30 mm Hg, and agents
    such as nitric oxide lower cardiac output
    by 15%.
Jassal, D. Perioperative Cardiac Management. eMedicine. January, 2008.
                           Surgical Risk
    Related to hemodynamic
     stress of the procedure
    High Risk
         >5% risk of perioperative
          death or MI
         emergent major surgery,
          peripheral vascular or
          aortic surgery, prolonged
          surgery involving
          excessive blood loss
Fleisher, et al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and
Care for Noncardiac Surgery: Executive Summary. Circulation. 2007;116:1971-1996.
                    Moderate Risk
   Moderate Risk
       1-5% risk of perioperative
        death or MI
       Carotid endarectomy and
        urologic, orthopedic,
        uncomplicated
        abdominal, head, neck,
        and thoracic operations
                          Low Risk

   Low Risk
       <1% risk
       Cataract removal, endoscopy,
        superficial procedure,
        cosmetic procedures, and
        breast surgery
              Stratifying Patient Risk
   Clinical markers
        Major clinical predictors - Unstable coronary syndrome, decompensated CHF,
         significant arrhythmia, and severe valvular disease
        Intermediate clinical predictors - Mild angina, prior MI, compensated or prior
         CHF, diabetes mellitus, and renal insufficiency
        Minor clinical predictors - Advanced age, abnormal findings on echocardiography,
         rhythm other than sinus, history of stroke, low functional capacity, and
         uncontrolled hypertension
   Functional capacity
        Poor functional class (<4 METS) - Energy expended during activities, including
         dressing, eating, and walking around the house
        Adequate functional class (>4 METS) - Energy expended during activities,
         including walking up a flight of stairs, scrubbing floors, and swimming
        For reference, sleeping = 1 MET
   Other risk factors
        Smoking, Alcohol abuse

                                      Fleisher, et al. 2007.
                        METs
   “Metabolic Equivalent”
   3.5 mL O2/kg/min, or sitting and reading




                      Mangano et al. 1990
                     Algorithm
   If surgery is an emergency then proceed to the OR. If
    not, then
   If the patient has undergone coronary revascularization
    in the past 5 years without recurrent ischemic
    symptoms, then proceed to the OR. If not, then
   If the patient has undergone coronary revascularization
    in the past 2 years, and no change in symptoms then
    proceed to the OR. If not, then
        Major Clinical Predictors
   If the patient has any of the major clinical
    predictors then the problem has to be addressed
    before surgery
     Unstable coronary syndrome
     decompensated CHF

     significant arrhythmia

     and severe valvular disease (aortic stenosis!)
         Intermediate Predictors
   Intermediate clinical predictors - Mild angina,
    prior MI, compensated or prior CHF, diabetes
    mellitus, and renal insufficiency
   Assess functional status. If < 4 METs, consider
    non-invasive testing. If > 4 METs and
    intermediate or low risk surgery, proceed to the
    OR
              Minor Predictors
   Advanced age, abnormal findings on
    echocardiography, rhythm other than sinus,
    history of stroke, low functional capacity, and
    uncontrolled hypertension
     <4 METs and high-risk surgery, consider non-
      invasive testing
     If < 4 METs and intermediate or low-risk surgery
      proceed to OR
     If > 4 METs proceed to the OR
                                  Interventions
    Pharmacological vs. coronary
     revascularization
    Recently, the Coronary Artery
     Revascularization Prophylaxis trial
     demonstrated that in the short term, there is
     no reduction in the number of postoperative
     myocardial infarctions, deaths, or duration of
     stay in the hospital, or in long-term outcomes
     in patients who underwent preoperative
     coronary revascularization compared with
     patients who received optimized medical
     therapy.

    McFalls EO, Ward HB, Moritz TE, Goldman S, Krupski WC, Littooy F, Pierpont G, Santilli S, Rapp J, Hattler
    B, Shunk K, Jaenicke C, Thottapurathu L, Ellis N, Reda DJ, Henderson WG: Coronary-artery
    revascularization before elective major vascular surgery. N Engl J Med 2004; 351:2795–804
Preoperative Stress Testing
           Are the guidelines used?
   Poor adherence, especially when testing is indicated




Hoeks SE. Guidelines for cardiac management in noncardiac surgery are poorly
implemented in clinical practice: results from a peripheral vascular survey in the
Netherlands. Anesthesiology. 2007;107(4):537-44.
             Is it harming patients?
   Legner VJ. Clinician agreement with perioperative
    cardiovascular evaluation guidelines and clinical
    outcomes. Am J Cardiol. 2006;97(1):118-22.
       864 Patients, prospective study
       Found that clinicians ordered testing half of the times it was
        recommended, lower rate of complications when ACC/AHA
        guidelines were not followed
       Frequency of complications not higher when guidelines not
        followed in general
                           References
   Fleisher, et al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular
    Evaluation and Care for Noncardiac Surgery: Executive Summary.
    Circulation. 2007;116:1971-1996
   Hoeks SE. Guidelines for cardiac management in noncardiac surgery are
    poorly implemented in clinical practice: results from a peripheral vascular
    survey in the Netherlands. Anesthesiology. 2007;107(4):537-44.
   Jassal, D. Perioperative Cardiac Management. eMedicine. 1/16/2008
   Legner VJ. Clinician agreement with perioperative cardiovascular evaluation
    guidelines and clinical outcomes. Am J Cardiol. 2006;97(1):118-22.
   Mangano, DT. Association of perioperative myocardial ischemia with cardiac
    morbidity and mortality in men undergoing noncardiac surgery. The Study of
    Perioperative Ischemia Research Group. N Engl J Med. 1990 Dec
    27;323(26):1781-8.
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