Download Preoperative Management of Cardiac Patients Undergoing

Preoperative Management of
Cardiac Patients Undergoing
Noncardiac Surgery.
Prof.Dr. Rasim Enar
CTF Cardiyoloji ABD.
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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.
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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.
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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.
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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):
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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):
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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 <65 yaşına
göre 10 kat daha yüksek)
 Type of major surgery.
 Previous Mİ.
 Unstable or CCS class 3 and 4 angina.
 Cardiac failure, present and past.
 Severity of aortic stenosıs.
 Presence of significant arrhythmia.
Cardiac Contraindications to Elective
Noncardiac Surgery:
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Myocardial infarction < 6 months.
Overt heart failure.
Severe Aortic stenosis.
Unstable angina.
Mobitz type II, complete AV block, sick sinus
syndrome.
Clinical Predictors increased Perioperative
Cardiovascular Rısk (Mİ,CHF, Death):
MAJOR:
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Unstable coronary syndrome.
Recent MI (as >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:
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Mild angina pectoris (CCS class –I or - II).
Prior MI by history or pathological Q waves.
Companseted congestive HF.
Diabetes Mellitus.
Renal insuffıciency.
MİNOR:
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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 newonset HF).
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3- Significant arrhytmias:
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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:
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Severe aortic stenosıs ( mean pressure
gradient >40 mmHg, aortic valve area < 1.0
cm2, or symptomatic patient).
Symptomatic mitral stenosis ( progressive
dyspne on exertıon, exertıonal presyncope,
or HF).
Cardiac Risk Stratification for Surgical Noncardiac
Procedures (combined incidence of cardiac death and
nonfatal MI)
1- Reported cardiac risk: more than %5.
Emergent major operations: Aortic and other major vascular
peripheral surgery (particularly elderly people).
Anticipated prolonged surgical procedures associated with large fluid shifts
and blood loss.
2- İntermediate cardiac risk: %1- %5.
Intraperitoneal and intrathoracic surgery.
Carotid edarterectomy. Head and neck surgery.
Orthopedic surgery.
Prostate surgery.
3- Cardiac risk: Less than %1. Not generally reguire further
preoperative cardiac testing.
Endoscopic procedures. superficial procedure.
Kataract surgery, breast surgery, ambulatory surgery.
Cardiac risk index evaluatıon with patient’s clinical
features (history, physical examinatıon) does not take
into consideratıon vital information may be gleaned
by noninvazive test:
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Electrocardıography.
Echocardıography (EF).
Exercise stress testing (Estimated MET: Metabolic
equivalent).
Thallium scintigraphy (dipyridamole, stress).
Holter monitorig (for silent ischemia and arrythmia).
İndications of Coronary angiography in
perioperative evaluatıon before (or after)
noncardiac surgery:
Patient with suspected or known CAD:
1- Evidence for high risk of adverse outcome based
noninvasive test results.
2- Angina unresponsive to adeguate medical
therapy.
3- Unstable angina, particullarly when facing
intermediate- risk or high- risk noncardiac
surgery.
4- Equivocal noninvasive test results in patients at
clinical risk undergoing high- risk noncardiac
surgery.
Comorbid Disease (I):
Associated conditions often highten risk of
anesthesia and may complicate cardiac
management. The most common of these
conditions discussed below.
Comorbid Disease(II):
Pulmonary Disease:- The presence either restrictive or obstructive
pulmonary disease; increased risk of perioperative respitatory
complicatiomns:- Hypoxemia, hypercapnia, acidosis, and increased
work of breathing;- all lead to further deterioration of an already
compromised cardiopulmonary system.
Diabetes Mellitus:- Diabetes mellitus is the most common
metabolic diseases which accompany cardiac disease;- Its
presence heighten suspicion of CAD, because CAD and
myocardial ischemia are more likely in patients with diabetes
mellitus.
Renal impairment:- Azotemia commonly associated with cardiac
disease and is associated with an increased risk of cardiovascular
events.Maintenance of adeguate intravascular volume for renal
perfusıon during diüresis of a patient with HF is often challenging.
Preoperative creatinin levels ≥2 mg/dL identified as a risk factor for
postop. renal dysfonctıon.
Hematologic Disorders:- Anemia, imposes stress on the
cardiovascular system thatmay exacerbate myocardial ischemia
and aggravate HF. 30 day postop. Mortality and cardiac morbidity
begin to rise when Hct. Levels decrease < %39 or exceed %51.
Factors Decrease Risk of Elective Noncardiac
Surgery:
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Coronary bypass surgery.
Angioplasty in patients with impaired coronary
reserve, EF> %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.