Preoperative Management of Cardiac Patients Undergoing Noncardiac Surgery.

1. Preoperative Management of Cardiac Patients Undergoing Noncardiac Surgery. Prof.Dr. Rasim Enar CTF Cardiyoloji ABD.

2. 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. • 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).

3. 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. • 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.

4. 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. 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.

5. Pathophysıology of Cardıologıc Complicatıons From Surgery (I): • 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.

6. Pathophysıology of Cardıologıc Complicatıons From Surgery (II): • 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.

7. 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.

8. Cardiac Contraindications to Elective Noncardiac Surgery: • Myocardial infarction < 6 months. • Overt heart failure. • Severe Aortic stenosis. • Unstable angina. • Mobitz type II, complete AV block, sick sinus syndrome.

9. Clinical Predictors increased Perioperative Cardiovascular Rısk (Mİ,CHF, Death): MAJOR: • 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.

10. INTERMEDİATE: • Mild angina pectoris (CCS class –I or - II). • Prior MI by history or pathological Q waves. • Companseted congestive HF. • Diabetes Mellitus. • Renal insuffıciency. MİNOR: • 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.

11. 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 new-onset HF). 3-Significant arrhytmias: • 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.

12. Active cardiac conditions for Which patient Should Undergo Evalutıon and treatment before Noncardiac Surgery (II): 4-Severe valvular disease: • 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).

13. 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.

14. 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: • Electrocardıography. • Echocardıography (EF). • Exercise stress testing (Estimated MET: Metabolic equivalent). • Thallium scintigraphy (dipyridamole, stress). • Holter monitorig (for silent ischemia and arrythmia).

15. 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.

16. Comorbid Disease (I): Associated conditions often highten risk of anesthesia and may complicate cardiac management. The most common of these conditions discussed below.

17. 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.

18. Factors Decrease Risk of Elective Noncardiac Surgery: • 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.