Perioperative cardiac assessment

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Perioperative cardiac assessment

  1. 1. non cardiac surgery represent pt first opportunity to receive appropriate assessment for both short term and long term cardiac risk thus this is the ideal opportunity to effect the long term treatment of pt with significant cardiac disease or risk of such disease. thus the referring phycisian should be inform the result of evaluation and implication of pt prognosis should not use the phrase " clear for surgery'
  2. 2. ability to perform activities of daily living. express aerobic demands for specific activities.
  3. 3. Activities that require more than 4 METs include moderate cycling, climbing hills, ice skating, roller blading, skiing, singles tennis, and jogging
  4. 4. Patient should undergo evaluation and treatment before non cardiac surgery
  5. 5. 9 indipendant risk factors evaluated on a point scale
  6. 6. In patients without documented CAD, surveillance should be restricted to those patients who develop perioperative signs of cardiovascular dysfunction.
  7. 7. Some procedures may be short, with minimal fluid shifts, whereas others may be associated with prolonged duration, large fluid shifts, and greater potential for postoperative myocardial ischemia and respiratory depression.
  8. 8. vascular surgery --> clinicians should incorporate the similarly poor long-term survival rates that accompany these procedures into their decision-making processes. intermediate-risk category --> morbidity and mortality vary depending on the surgical location and extent of the procedure.
  9. 9. In many instances, patient- or surgery- specific factors dictate an obvious strategy (eg, emergency surgery) that may not allow for further cardiac assessment or treatment. Step 3: Is the patient undergoing low-risk surgery? Many procedures are associated with a combined morbidity and mortality rate less than 1% (see Section 4), even in high-risk patients. Interventions based on cardiovascular testing in stable patients would rarely result in a change in management, and it would be appropriate to proceed with the planned surgical procedure
  10. 10. Step 4: Does the patient have a functional capacity greater than or equal to 4 METs without symptoms? Functional status has been shown to be reliable for perioperative and long-term prediction of cardiac events In highly functional asymptomatic patients, management will rarely be changed based on the results of any further cardiovascular testing. It is therefore appropriate to proceed with the planned surgery. In patients with known cardiovascular disease or at least 1 clinical risk factor, perioperative heart rate control with beta blockade appears appropriate as outlined in Section 7.2. Step 5: If the patient has poor functional capacity, is symptomatic, or has unknown functional capacity, then the presence of clinical risk factors will determine the need for further evaluation.
  11. 11. active vs sedentary lifestyle active , asymptomatic, run for 3 mins- may need no further evaluation sedentary, asymptomatic, but with clinical risk factor -- more extensive preoperative evaluation
  12. 12. In general, indications for further cardiac testing and treatments are the same as in the nonoperative setting The use of both noninvasive and invasive preoperative testing should be limited to those circumstances in which the results of such tests will clearly affect patient management.
  13. 13. routine coronary revascularization in pt with stable cardiac symptoms before major vascular surgery -- does not alter the long term outcome and short term risk of death/ MI
  14. 14. Clarification of these questions is an important goal of the preoperative history and physical examination, and selected noninvasive testing is used to determine the patient’s prognostic gradient of ischemic response during stress testing.
  15. 15. delay surgery to optimize effect of anti HPT
  16. 16. which can increase the volume of regurgitation by increasing the duration of diastole. Tachycardia thus reduces the time of regurgitation in severe aortic regurgitation
  17. 17. Prevention of Bacterial Endocarditis, Recommendations by the American Heart Association, JAMA, 11 June 1997; 277: 1794-1801
  18. 18. unschedule non cardiac surgery in a pt who has undergone a prior PCI present special challenges with regards of management of dual antiplatelets agents required.
  19. 19. unschedule non cardiac surgery in a pt who has undergone a prior PCI present special challenges with regards of management of dual antiplatelets agents required.
  20. 20. risk of bare-metal stent thrombosis diminishes after endothelialization of the stent has occurred (which generally takes 4 to 6 weeks), it appears reasonable to delay elective noncardiac surgery for 4 to 6 weeks to allow for at least partial endothelialization of the stent, but not for more than 12 weeks, when restenosis may begin to occur risk of bare-metal stent thrombosis diminishes after endothelialization of the stent has occurred (which generally takes 4 to 6 weeks), it appears reasonable to delay elective noncardiac surgery for 4 to 6 weeks to allow for at least partial endothelialization of the stent, but not for more than 12 weeks, when restenosis may begin to occur..
  21. 21. because of concerns about late-stent thrombosis.
  22. 22. The thienopyridines and aspirin inhibit platelet aggregation and reduce stent thrombosis but increase the risk of bleeding.
  23. 23. Significant surgical procedures include major abdominal or thoracic surgery, particularly when the surgery involves large amounts of electrocautery.
  24. 24. the availability of expertise in pacing and/or ICDs
  25. 25. The electrical current generated
  26. 26. Efforts should be made to minimize the chance for interactions by
  27. 27. Therefore, a discussion of these issues before the planned surgery will allow for a smooth transition through the perioperative period.

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