Professional Documents
Culture Documents
↑ Oxygen demand
Risk Evaluation/Statification/Modification
Clinical Predictors of Increased
Perioperative Cardiovascular Risk
Major Clinical Predictors Intermediate Clinical Predictors
Unstable Coronary Syndromes
Acute or recent MI with evidence of
Mild angina pectoris (Canadian
important ischemic risk by clinical Class I or II)
symptoms or noninvasive study
Unstable or severe angina (Canadian Previous MI by history or
Class III or IV)
pathological Q waves
Decompensated heart failure
Significant Arrhythmias Compensated or prior heart
High-grade AV block failure
Symptomatic ventricular arrhythmias in
the presence of underlying heart disease Diabetes Mellitus (particularly
Supraventricular arrhythmias with
insulin-dependent)
uncontrolled ventricular rate
Severe Valvular Heart disease Renal Insufficiency
GRADES OF ANGINA
Canadian Classification of Angina
Class 0: Asymptomatic
Class 1: Angina with strenuous exercise
Class 2: Angina with moderate exertion
Class 3: Angina with mild exertion
1. Walking 1-2 level blocks at
normal pace
2. Climbing 1 flight of stairs at
normal pace
Class 4: Angina at Rest
FUNCTIONAL CAPACITY
Revascularisation before
non-cardiac surgery
Coronary-artery revascularization
before elective major vascular
surgery
ACC/AHA 2004 Guideline Update for
Coronary Artery Bypass Graft Surgery
Benefit of CABG
GNL 2011
Long-Term Survival among Patients Assigned to Undergo
Coronary-Artery Revascularization or No Coronary-Artery
Revascularization before Elective Major Vascular Surgery
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author
2009. For permissions please email: journals.permissions@oxfordjournals.org
Patients With Bare Metal Stents
Undergoing Non-cardiac Surgery
A review on 424 patients with mostly BMSs suffered 82
adverse outcomes after non-cardiac surgery. There
were 6.6% cardiac death,5.4% non-fatal MI, and 5.4%
had evidence of myocardial damage.
< 14 days > 14 days < 30-45 days > 30-45 days < 365 days > 365 days
Thyroidectomy …. ??
Preoperative Risk Modification And Optimization
Beta Blockers
Beta-blockade – Landmark Trials
Mangano DT et al. N Engl J Med 1996; 335: 1713-20.
2- year survival =
79%
Cardiac
death or
non-fatal
MI
Perioperative beta-blockade…what’s new
Recent Trials Showing No Benefit When Administered
In Unselected Patients
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author
2009. For permissions please email: journals.permissions@oxfordjournals.org
Beta blocker use?
Risk evaluation and cardiac complications in patients
undergoing major vascular surgery
2009 focussed update recommendations for
perioperative beta-blocker use
Perioperative cardiac care:
Beta-blockade…bottom line
For patients chronically receiving beta-blockers
continue perioperatively
Which patients may benefit from prophylactic beta-
blockade, if any, is uncertain.
My opinion:
High risk patients (RCRI ≥3) are likely to benefit
Must be started days to weeks before surgery with dose
titration to achieve resting heart rate < ~70 bpm
Preoperative Risk Modification And Optimization
Statins
The Emerging Benefits
Statin
Lipid lowering effect Cardioprotective property
Statin
lipid TIMP-1
Lipid inflammation
Matrix metalloproteinase-2
Cell death
Statin
Statins
The ASTEROID trial :
Significant regression of atherosclerosis after intensive statin therapy
( rosuvastatin 40mg low LDL 60.8 mg/dl, increased HDL 14.7% )
Leurs et al. :
In patients who underwent endovascular abdominal aortic aneurysm repair,
overall mortality rate at 5 years of follow-up was lower in those using statins,
compared to those not using statins
↓Incidence of stroke
Strength of evidence for perioperative use of statins to
BMJreduce
2006; 333:1149
cardiovascular risk: systematic review of controlled studies
Statin - ongoing
DECREASE III study :
the effect of statin therapy on perioperative inflammatory
response and whether a reduced inflammatory response is
associated with improved cardiovascular outcome.
DECREASE IV trial :
whether β-blockers, statins or the combination of β-blockers
and statins are beneficial in 6000 moderate to high-risk
noncardiac, nonvascular surgery patients
DECREASE IV showed that in intermediate-risk patients undergoing non-cardiac surgery,
bisoprolol or bisoprolol plus fluvastatin significantly reduced 30-day cardiac death and
myocardial infarction.
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author
2009. For permissions please email: journals.permissions@oxfordjournals.org
Preoperative Risk Modification And Optimization
Other agents/options
Calcium channel blocker Nitroglycerin
Other agents/options
α2 adrenergic agonist
α2 Adrenergic Agonists
clonidine, dexmedetomidine, mivazerol
• Temperature monitoring
• CVP monitoring
• Pulmonary artery catheterization
INVASIVE MONITORING
INDICATIONS :
• Hemodynamically unstable patients
• Major surgeries involving large fluid shifts &blood loss
• Pts. with acid-base &electrolyte imbalance
• To optimize fluid therapy
Pulmonary Artery Catheters
Systole
Systole
Balloon
deflates
9/25/18 WE Ellis 78
IABP
Diastole
Systole
Diastole
Balloon
inflates
9/25/18 WE Ellis 79
IABP
Systole
Systole
Balloon
deflates
9/25/18 WE Ellis 80
Case Presentation
50 yr old man with chest pain for
fem-pop bypass.
Hx:
stable angina and old MI (plasty 7 yrs ago)
no CHF or valvular disease
DM, HTN, smoker
fitness level: walks 30 minutes ok
Case Presentation
Physical Exam
normal airway
lungs clear to auscultation
CVS:
no cardiomegaly
no S3
no murmurs
Case Presentation
Meds
beta blocker, ACE I, NTG prn
Labs
Cr is elevated
all other values normal
Case Presentation
Investigations:
ECG shows Q waves anteriorly. Otherwise is
normal sinus rhythm with borderline LVH
Echo shows (4 years ago):
EF 35%
normal valves
mild dilated cardiomyopathy
Preoperative Risk (AHA)
1. Are there any major patient risk factors?
no
2. Are there any medium risk factors?
yes: CRF, old MI, DM
3. Is the patient`s fitness level poor?
no, fitness is ok
4. Is this a high risk surgery?
yes
Preop Management
1. Is invasive testing indicated?
no: no major risk factors present
2. Is non-invasive testing indicated?
3 medium risk factors
high risk surgery
good fitness level
2 out of 3, therefore yes, it is indicated
3. Ok to proceed to surgery?
no
Preop Testing
A cardiology consult is requested and the patient
receives an exercise treadmill test. The results are
favorable and no invasive monitoring is indicated.
Preop Preparation
Which drugs should be continued/stopped?
beta blocker?
continue!
ACE I?
stop (can result in vasodilation and BP)
NTG?
… is prn and therefore not given
Antiplatelet therapy?
to continue with Aspirin, may stop Clopidogrel.
Anesthetic Monitors?
NIBP
SpO2
ECG … 3 lead or 5 lead?
A line?
CVP?
PA catheter?
TEE?
Emergency CVS Drugs?
ephedrine (yes)
phenylephrine?
IV beta blocker?
IV NTG?
dopamine?
dobutamine?
Anesthetic Technique
General vs. Neuraxial?
(neuraxial = spinal or epidural)
“CRRAP”
Anesthetic CVS Goals
C: low ( MVO2)
R: low ( diastolic perfusion + MVO2)
R: sinus
A: low ( MVO )
2
P: low ( MVO2)
Maintain BP/CPP
Need a diagnosis:
is O demand a contributor?
2
is O2 supply a contributor?
Please discuss!
O2 Demand
HR of 100 is moderately high
afterload not elevated
contractility unknown
O content of blood
2
O content of blood
2
yes
Blood pressure
use vasopressors
avoid inotropes
increased HR and contractility
ensure adequate preload
Diastolic Time
Elevated HR caused by:
inadequate anesthesia
inadequate preload
anemia
hyperthermia
Oxygen Content/Delivery of Blood
Determined by:
Hb
SaO2
CO
Back to the Case
Look at the filling pressures
there has been 1000 cc of blood loss
Hb=8.0 CVP=5 90/50 HR=100