Perioperative Cardiovascular Management

and Shawn A. Gregory1



(1)
Harvard Medical School Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA

 



Introduction

General Approach [, ]

Rationale for Perioperative Cardiovascular Consultation

History – Assess

Physical Examination (Table )

Preoperative Cardiovascular Testing

Perioperative Medications

Coronary Revascularization

Special Topics

Integrated Approach (Fig. )

Postoperative Management

References


Abstract

The cardiologist is frequently called upon to assist in the management of patients with cardiovascular disease in the perioperative setting. Questions surrounding risk stratification, risk management, diagnostic testing, management of cardiovascular medications, and revascularization, among others, are germane to the optimal management of such patients. The cardiovascular consultant must be prepared to approach these questions in a systematic and evidence-based fashion.


Abbreviations


ACE

Angiotensin converting enzyme

CAD

Coronary artery disease

CVD

Cardiovascular disease

ECG

Electroc ardiography

ICD

Implantable cardioverter defibrillator

INR

International normalized ratio

LAD

Left anterior descending

LV

Left ventricular

LVEF

Left ventricular ejection fraction

MI

Myocardial infarction

PAD

Peripheral artery disease

PCI

Percutaneous coronary intervention



Introduction


The cardiologist is frequently called upon to assist in the management of patients with cardiovascular disease in the perioperative setting. Questions surrounding risk stratification, risk management, diagnostic testing, management of cardiovascular medications, and revascularization, among others, are germane to the optimal management of such patients. The cardiovascular consultant must be prepared to approach these questions in a systematic and evidence-based fashion.


General Approach [1, 2]






  • Define the question


  • Establish urgency


  • Gather primary data


  • Provide concise recommendations


  • Offer contingency plans


  • Offer narrow recommendations within consultant’s purview


  • Educate, when appropriate


  • Communicate directly


  • Follow up on recommendations


  • For the cardiovascular consultant:



    • Conduct history and physical examination


    • Consider ancillary testing


    • Stratify risk based on the above


    • Weigh strategies to reduce risk


Rationale for Perioperative Cardiovascular Consultation




A.

Over one million cardiac complications, including 50,000 perioperative myocardial infarctions (MI), occur annually [3].



  • Cardiac complications cause over 50 % of perioperative deaths


  • Cardiac complications prolong hospitalization by a mean of 11 days


  • Total cost: Over $20,000,000,000 annually [4]

 


History – Assess






  • Personal and family history of cardiovascular disease


  • Risk factors for cardiovascular disease



    • Hypertension


    • Hyperlipidemia


    • Smoking


  • Symptoms suggestive of cardiovascular disease: chest pain; dyspnea; palpitations; syncope; edema


  • Functional capacity (Fig. 30-1):

    A306999_1_En_30_Fig1_HTML.gif


    Figure 30-1
    Functional capacity (Adapted from Fleisher et al. [2] and Hlatky et al. [5])


  • Co-morbid disease



    • Pulmonary disease


    • Diabetes mellitus


    • Renal disease


    • Hematologic disorders


  • Urgency and risk of procedure



    • If emergency noncardiac surgery is required (e.g., death or major complications are very likely or certain without surgery), proceed to surgery without further cardiovascular evaluation (Class IC)


    • If noncardiac surgery is not emergent, assess risk of surgery (Table 30-1):


      Table 30-1
      Risk of surgery





































      Risk category
      Example

      Vascular (reported cardiac risk often more than 5 %)
      Aortic and other major vascular surgery

      Peripheral vascular surgery

      Intermediate (reported cardiac risk generally 1–5 %)
      Intraperitoneal and intrathoracic surgery

      Carotid endarterectomy

      Head and neck surgery

      Orthopedic surgery

      Prostate surgery

      Low (reported cardiac risk generally less than 1 %)
      Endoscopic procedures

      Superficial procedure

      Cataract surgery

      Breast surgery

      Ambulatory surgery


      Adapted from Fleisher et al. [6]




      • Further testing and/or therapy and as described below


Physical Examination (Table 30-2)





Table 30-2
Physical examination in peri-operative assessment































Examination component
Findings that should prompt additional investigation

Vital signs
Hypotension, hypertension, tachycardia, bradycardia

Carotid pulse
Bruits, abnormal pulse contour

Jugular venous pressure/pulse
Elevation or abnormal contour

Pulmonary auscultation
Crackles, wheezing; dullness to percussion suggestive of pleural effusion

Cardiac auscultation
Murmurs (particularly if loud, harsh, or associated with other findings suggestive of heart failure or other pathology), irregular rhythm

Peripheral pulses
Diminished (particularly if associated with bruits and/or limb discoloration)

Edema
If severe, unilateral, or associated with other findings of heart failure


Preoperative Cardiovascular Testing




A.

Electrocardiography (ECG)



  • Provides prognostic information in patients with active cardiac conditions, e.g., ischemia, arrhythmia


  • Preoperative 12-lead ECG is recommended for:



    • Patients with known coronary artery disease (CAD), peripheral artery disease (PAD), or cardiovascular disease (CVD) undergoing intermediate-risk surgery (Class I)


    • Patients with at least one clinical risk factor undergoing vascular surgery (e.g., hypertension, hyperlipidemia, smoking; Class I) [6]


    • Preoperative 12-lead ECG is NOT recommended for asymptomatic patients undergoing low-risk procedures (Class III) [7]

 

B.

Noninvasive (Stress) Testing



  • Provides an objective measure of functional capacity; identifies myocardial ischemia; and estimates perioperative cardiac risk and long-term prognosis


  • Patients with active cardiac issues do not require testing; they should be treated for the active condition (Class I)


  • Noninvasive testing should NOT be performed in patients without clinical risk factors undergoing intermediate-risk surgery or in patients undergoing low-risk surgery (Class III)


  • Exercise stress test favored over other modalities, if possible; choice of adenosine/regadenason/dobutamine/dipyridamole and/or imaging depends on local expertise and patient characteristics (e.g., avoidance of dobutamine in patients with ventricular arrhythmia, avoidance of adenosine in patients with bronchospasm) [8]

 

C.

Echocardiography



  • Provides a measure of left ventricular (LV) function; identifies and characterizes valvular disease



    • May be indicated if:



      • Physical examination or other data are suggestive of worsening or previously undiagnosed heart failure and/or valvular disease


  • Routine perioperative evaluation of LV function is of limited utility and is NOT recommended (Class III) [9]

 


Perioperative Medications




A.

Beta-blockers



  • Initially thought to decrease perioperative ischemia in high-risk patients



    • In early trials, dramatic reduction in early events [10]


    • No difference for in-hospital morbidity/mortality but decreased morbidity/mortality at 2 years [11]


  • Subsequent studies less promising



    • POBBLE, MaVS, DIPOM trials: no benefit [12–14]


    • POISE: Largest study, high risk patients undergoing intermediate-to-high risk surgery; metoprolol reduced non-fatal MI but increased stroke and total mortality [15]


  • Salutary effects in patients with arrhythmia (e.g., rate control) and cardiomyopathy (e.g., neurohormonal blockade)


  • Beta -blockers are indicated in patients who:



    • Are already receiving beta-blockers (Class I)


    • Are high risk and undergoing vascular surgery (Class I)


  • Beta -blockers are NOT indicated in patients with:



    • Absolute contraindication(s) to beta blockade (Class III)

 

B.

Antiplatelet Agents

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Jul 13, 2016 | Posted by in CARDIOLOGY | Comments Off on Perioperative Cardiovascular Management

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