Discussion w1-2 654

Q-1

The preoperative cardiac evaluation must be carefully tailored to the circumstances that have prompted the consultation and to the nature of the surgical illness as opposed to urgent or elective cases. Successful perioperative evaluation and treatment of cardiac patients undergoing noncardiac surgery requires careful teamwork and communication between the patient, primary care physician, anesthesiologist, consultant, and surgeon. In general, indications for further cardiac testing and treatments are the same as those in the nonoperative setting, but their timing is dependent on such factors as the urgency of surgery, the patient’s risk factors, and specific surgical considerations. Coronary revascularization before surgery to enable the patient to “get through” the procedure is appropriate only for a small subset of patients at very high risk. Preoperative testing should be limited to circumstances in which the results will affect patient treatment and outcomes (Sklyar & Bella, 2017).

For example, a patient will uncontrolled hypertension should be controlled before surgery. In many such instances, establishment of an effective regimen can be achieved over several days to weeks of preoperative outpatient treatment. If surgery is more urgent, rapid-acting agents can be administered that allow effective control in a matter of minutes or hours. Beta-blockers appear to be particularly attractive agents. Continuation of preoperative antihypertensive treatment through the perioperative period is critical. Specific recommendations for supplemental preoperative evaluation must be individualized to each patient and circumstance. The following may be appropriate in more situations: assessment of resting left ventricular function, exercise stress testing, pharmacological stress testing, ambulatory ECG monitoring, and coronary angiography (Caplan & Yu, 2018). 

 

Caplan, J., & Yu, W. (2018). Preoperative cardiac evaluation of patients uncontrolled HTN. American journal of Cardiology (Belle Mead, N.J.), 37(1), 32–36. 

Sklyar, E., & Bella, J. N. (2017). Cardiac Evaluation and Monitoring of Patients Undergoing Noncardiac Surgery. Health services insights, 9, 1178632916686074. https://doi.org/10.1177/1178632916686074

Q-2

A 40-year-old male patient with PMH of CAD, MI with a cardiac stent, chronic angina, chronic smoker admitted for pain on his right leg and for consideration for peripheral vascular surgery (PVS) on his right leg for peripheral arterial disease (PAD). The clinical characteristic of his condition is now probably an extension of his vascular disease to his periphery or diffuse vascular disease. Peripheral vascular disease is primarily driven by the progression of atherosclerotic disease leading to macro and microvascular dysfunction which typically affects lower extremity vascular beds. Larger arteries such as the abdominal aorta and iliac arteries are frequently involved, and more severe forms involve multivessel or diffuse disease. A detailed health his toey including lifestyles such as smoking, exercise, diet, intake of coffee or soft drinks, use of illicit drugs and alcohol, current medications, recent hospitalizations, and a thorough physical examination and diagnostic tests were needed and ordered. Considering his cardiac history is a major concern for surgery until unless his condition and tests results prove that he is cleared for surgery. Peripheral vascular surgery patients' have an increased risk of postoperative myocardial infarction and/or death due to unrecognized coronary ischemia around 65 percentage (Krievins et al, 2019).

I would be doing a baseline CBC to evaluate the patient for anemia, infection or inflammation and platelet abnormalities and a BMP to evaluate any electrolyte imbalances, diabetes, and renal impairments, Lipid panel to evaluate for hyperlipidemia, Urine analysis to see any albuminuria due to hypertension, a baseline EKG to evaluate the presence of any new ischemia. An echocardiogram to evaluate the pressures in the chamber, any valvular and structural changes due to hypertension and MI, and his ejection fraction for any impaired pumping action. Since this patient has chronic angina with a history of MI with stents, I would also consult a cardiology opinion to evaluate whether he needs his angiography to visualize his coronaries. An EKG stress test is indicated for all noncardiac pre-op surgery patients for better prognostic value along with complimentary cardiac exams (Marcadet, 2019). An ultrasound Doppler study of both lower extremities and a CT angiography or an MRA will rule out the extend of occlusion on the affected leg. Since the patient is actively smoking, he needs a chest x-ray to evaluate any hyperinflation, COPD, pulmonary hypertension, or even lung cancers. Hence, I would also order complementarity tests such as PFT to evaluate his lung function. Measurement of the ankle-brachial index (ABI) is a cost-effective non-invasive objective measure for PAD diagnosis (Gul, & Janzer, 2021). A pre-op coronary computed tomography-derived fractional flow reserve (FFRCT) can help guide a multidisciplinary team approach to reduce postoperative cardiac events in PVS patients' (Krievins et al, 2019). Assessment of PAD risk score with risk facto0rs such as smoking diabetes, hypertension, hypercholesteremia, and obesity (Gul, & Janzer, 2021).

 

Reference.

Krievins, D., Zellans, E., Erglis, A., Zvaigzne, L., Kumsars, I., Latkovskis, G., ... & Zarins, C. (2019). TCT-332 Pre-Op Diagnosis of Silent Coronary Ischemia Using CT-Derived Fractional Flow Reserve May Reduce Post-Op MI and Death in Patients Undergoing Peripheral Vascular Surgery. Journal of the American College of Cardiology, 74(13S), B330-B330. Retrieved from https://www.jacc.org/doi/full/10.1016/j.jacc.2019.08.413

Marcadet, D. M. (2019). Exercise testing: New guidelines. Presse medicale (Paris, France: 1983), 48(12), 1387-1392. Retrieved from

https://europepmc.org/article/med/31679896

Gul, F., & Janzer, S. F. (2021). Peripheral vascular disease. StatPearls [Internet].

https://www.ncbi.nlm.nih.gov/books/NBK557482/

Q-3

A large number of patients 65 years and older undergo elective surgery and are at increased risk for complications, particularly those with cardiovascular and pulmonary diseases. In the elderly during surgery, diminished arterial and left ventricular compliance, impaired vasoconstriction, altered autonomic function and sensitivity to catecholamines, may all impair the maintenance of cardiovascular homeostasis. Furthermore, perioperative management is dependent on individual patient circumstances, the planned surgical procedure, and the patient's functional capacity (De hart et al., 2018).

For example, a 70-year-old patient with dilated cardiomyopathy is at risk for developing congestive heart failure and arrhythmias during surgery. A surgical, anesthesiologist, and cardiology consultation prior to elective surgery would be necessary for this patient to assist with the cardiac evaluation and risk-factor management and to determine whether the procedure should be postponed. Preoperative evaluation includes history, physical examination, taking note of the NYHA functional classification and the patient's history of arrhythmias, syncope, angina, and a personal or family history of sudden death would be noted. Preoperative diagnostics would include obtaining a baseline ECG followed by a postoperative ECG for comparison. Preoperative echocardiography can inform the perioperative management by providing estimates of systolic ejection fraction, the severity of diastolic dysfunction, and pulmonary artery pressure. Laboratory diagnostics would include a complete blood count, to get baseline hemoglobin, a BMP to assess kidney function, and a BMP. Some studies have shown that a high preoperative BNP value has independent prognostic significance to predict cardiac events and long-term mortality after surgery (Dhillon et al., 2019).

Management of drug therapy, including beta-blockers, diuretics, and nondihydropyridine calcium channel blockers would be individualized and continued in most cases. Anticoagulation is usually held prior to procedures with moderate to high bleeding risk unless they have a very high CHA2DS2Vasc score or recent embolic event within 3 months. Elective surgeries are generally recommended to be delayed unless it is urgent in patients with decompensated or untreated cardiomyopathy (Dhillon et al., 2019).

 

 

De Hert, S., Imberger, G., Carlisle, J., Diemunsch, P., Fritsch, G., Moppett, I., Solca, M., Staender, S., Wappler, F., Smith, A., & Task Force on Preoperative Evaluation of the Adult Noncardiac Surgery Patient of the European Society of Anaesthesiology (2018). Preoperative evaluation of the adult patient undergoing non-cardiac surgery: guidelines from the European Society of Anaesthesiology. European journal of anaesthesiology, 28(10), 684–722. https://doi.org/10.1097/EJA.0b013e3283499e3b

Dhillon, A., Khanna, A., Randhawa, M. S., Cywinski, J., Saager, L., Thamilarasan, M., Lever, H. M., & Desai, M. Y. (2019). Perioperative outcomes of patients with hypertrophic cardiomyopathy undergoing non-cardiac surgery. Heart (British Cardiac Society), 102(20), 1627–1632. https://doi.org/10.1136/heartjnl-2016-309442