• Nama : DR JETTY H SEDYAWAN SpJP K FIHA FAsCC

• Pekerjaan : Lektor Dep Kardiologi FKUI

• PENDIDIKAN : FKUI
- Invasive n Non Invasive St Vincents
Hospital Sydney, Australia
- Haemodynamic & Imaging Training
Mayo Clinic, Rochester, USA
- ACLS Instructur, ALS NSW Australia
- CCrISP/Perioperative Care Instructur
• Organisasi: Profesi, Pet lovers
• Lovers DR dr EDY SEDYAWAN MSc
DR Andhyka Putra Sedyawan
DR Ayuthia Putri Sedyawan SpJP.
,
HOBBY : Travelling, Diving, Dancing,Gardening
Motto: Count Your Blessings, not Your troubles
 Executive Summary of
Perioperative Non Cardiac Surgery

Jetty RH Sedyawan
DISCLOSURE STATEMENT OF FINANCIAL INTEREST
I, JETTY RH SEDYAWAN, DO NOT HAVE A FINANCIAL INTEREST/ARRANGEMENT OR
AFFILIATION WITH ONE OR MORE ORGANIZATIONS THAT COULD BE PERCEIVED AS
A REAL OR APPARENT CONFLICT OF INTEREST IN THE CONTEXT OF THE SUBJECT
OF THIS PRESENTATION.
Ketua IKABI
IKABI Convocation 2016
WHAT CAUSES PERIOPERATIVE CARDIOVASCULAR
EVENTS?
Catecholamnine surges
Prothrombotic mileu
Blood loss
Volume shifts
Coronary Plaque destabilization
Fixed coronary disease
 Question
• Should we intervene the ……. problem or treat it conservatively first?
• Evaluation for ……..intervention
• Non surgical vs surgical ……….. intervention
• Perioperative anticoagulant and or antiplatelet related with prosthetic
valve, Arrhythmia and or PCI
• Prophylactic antibiotics
What is the Purposes and Goals of
preoperative Cardiovascular evaluation ?

Grube E. et al, Am Journal Cardiol 2006; “in press”

 Purpose of Preoperative Evaluation
Evaluate patient’s current medical status
Provide clinical risk profile

Recommend management of cardiac risk over perioperative period

Treatment of modifiable risk factors

Successful perioperative evaluation and management of
highrisk cardiac patients undergoing noncardiac surgery
Grube E. et al, Am Journal Cardiol 2006; “in press”
Major
Minor
 Unstable coronary syndromes
 Advanced Age.
 Decompensated CHF
 Abnormal ECG.
 Significant Arrhythmias
 Rhythm other than sinus.
Intermediate
 Low functional capacity.
 Mild angina pectoris
 History of stroke.
 Prior MI
 Uncontrolled systemic
 Compensated or prior HF
hypertension
 Diabetes Mellitus and Renal insufficiency
Condition Examples
Unstable coronary syndromes  Unstable or severe angina* (CCS class III or IV)†
 Recent MI‡

Decompensated HF  NYHA functional class IV;

 Worsening or new-onset HF

Significant arrhythmias  High-grade atrioventricular block

 Mobitz II atrioventricular block
 Third-degree atrioventricular heart block
 Symptomatic ventricular arrhythmias
 Supraventricular arrhythmias (including atrial fibrillation) with uncontrolled ventricular rate (HR > 100 bpm at rest)
 Symptomatic bradycardia
 Newly recognized ventricular tachycardia

Severe valvular disease  Severe aortic stenosis (mean pressure gradient greater than 40 mm Hg, aortic valve area less than 1.0 cm2, or symptomatic)
 Symptomatic mitral stenosis (progressive dyspnea on exertion, exertional presyncope, or HF)

Active Cardiac Conditions

Grube E. et al, Am Journal Cardiol 2006; “in press”
Stepwise Approach for
Perioperative Cardiac
Assessment
Grube E. et al, Am Journal Cardiol 2006; “in press”
 Low Risk Surgical Procedure
• Identify risk factors
. Lifestyle & medical treatment based on guidelines

• Initiation of titrated low dose beta blocker before surgery (Class IIb/ Level B)
• ACEi in patient with heart failure & systolic dysfunction (Class IIa/ Level C)
• Initiation of statin therapy for vascular surgery (Class IIa/ Level B)
 Risk of Surgical Procedure
“30 day cardiovascular death & MI”
 Step 4
Intermediate/ High Risk Surgical Procedure
• Additional functional capacity (METS): ≥ 4 METS (good)
• Initiation of titrated low dose beta blocker before surgery (Class IIb/ Level B)
• ACEi in patient with heart failure & systolic dysfunction (Class IIa/ Level C)
• Initiation of statin therapy for vascular surgery (Class IIa/ Level B)

 Surgery
 Eur Heart J 2014;35:2383-2431
 Step 5
Consider risk of surgery
• Additional functional capacity (METS):
<4 METS (moderate or poor) with intermediate risk
surgical procedure
•Non invasive testing (Class IIb/ Level B)
•Baseline ECG (Class I/ Level C)

Cardiac Risk Factors
 Step 6
< 4 METS with High Risk Surgical Procedure
Cardiac Risk Factors
• If cardiac risk factors ≤2 
rest echo & biomarkers of LV
function (Class IIb/ Level B-C)
 Surgery

• If cardiac risk factors ≥3 

cardiac stress test (Step 7)
1. No/ moderate stress-induced ischaemia  Surgery
2. Extensive Ischaemia
ss

Step 7
SURGERY Eur Heart J 2014;35:2383-2431.
cardiac testing and treatments
The urgency of the surgery
Patient-specific risk factors

Surgery-specific considerations
Improved cardiac care for
noncardiac surgery?
Stepwise Approach for Perioperative Cardiac
Assessment
Scheduled with
known or risk
factor of CAD ? Low risk

Estimate periop No further

Emergency ? No ACS? No
Risk of MACE testing Surgery
Yes Yes

Clinical risk Evaluate &Treat Elevated

≥ 4 mets
risk
stratification and ACS
proceed to surgery Stress Ab Coronary
test n Revask