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Noncardiac Surgery in the Cardiac Patient David Putnam, MD Albany Medical College Coronary heart disease is the most frequent cause of perioperative cardiac mortality and morbidity after noncardiac surgery Noncardiac Surgery Magnitude of the Problem

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Noncardiac Surgeryin the Cardiac Patient

David Putnam, MD

Albany Medical College


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Noncardiac Surgery perioperative cardiac mortality and morbidity after noncardiac surgeryMagnitude of the Problem

  • 25 million patients undergo noncardiac surgery each year in the United States

  • 3 million patients have clinical evidence or multiple risk factors for CAD

  • 4 million patients are > 65 years old

  • Nearly 1/3 of surgical patients are at risk for cardiovascular complications


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Noncardiac Surgery perioperative cardiac mortality and morbidity after noncardiac surgeryMagnitude of the Problem

  • Aging of the population

  • Lower threshold for performing major procedures on elderly patients

  • Patients with multiple comorbid illnesses


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Noncardiac Surgery perioperative cardiac mortality and morbidity after noncardiac surgeryMagnitude of the Problem

  • Advances in anesthesia, post-op analgesia, and surgical technique have contributed to a reduced rate of major cardiac complications

  • Overall risk of cardiac complications with noncardiac surgery remains low

  • Risk of perioperative MI: 0.1%

  • Risk of cardiac death: 0.4%


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Non-Cardiac Surgery perioperative cardiac mortality and morbidity after noncardiac surgeryRisk of Perioperative MI/Death

  • No history of ischemic heart disease: 0.1%

  • History of prior MI: 6%


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Reinfarction in Post-MI Patients perioperative cardiac mortality and morbidity after noncardiac surgery


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Non-Cardiac Surgery perioperative cardiac mortality and morbidity after noncardiac surgery

  • Although consultants are frequently asked to “clear” a patient for surgery, their role is considerably more complex


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Noncardiac Surgery: General perioperative cardiac mortality and morbidity after noncardiac surgery

  • Successful perioperative evaluation and treatment of cardiac patients

  • Teamwork and communication between

    • Patient

    • Primary Care Physician

    • Anesthesiologist

    • Surgeon

    • Medical Consultant


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Preop: Role of Consultant perioperative cardiac mortality and morbidity after noncardiac surgery

  • Assess individual patient’s risk of cardiac complications

  • Determine if specialized testing is appropriate

  • Recommend risk reduction strategies

  • Participate in postoperative medical management


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Pre-Operative Cardiac Evaluation perioperative cardiac mortality and morbidity after noncardiac surgery

  • What is the question?


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Pre-Operative Cardiac Evaluation perioperative cardiac mortality and morbidity after noncardiac surgery

  • Can this patient reasonably have noncardiac surgery?


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Pre-Operative Cardiac Evaluation perioperative cardiac mortality and morbidity after noncardiac surgery

  • Would coronary revascularization improve the long-term prognosis from a cardiac standpoint and protect the patient from adverse events during the necessary noncardiac surgery?


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Preoperative Risk Assessment perioperative cardiac mortality and morbidity after noncardiac surgery

  • Dripps-ASA classification

  • Goldman classification

  • ACC recommendations


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ASA Physical Status Assessment perioperative cardiac mortality and morbidity after noncardiac surgery

  • Class I: Healthy patient/elective operation

  • Class II: Patient with mild systemic disease

  • Class III: Severe systemic disease that limits activity but is not incapacitating

  • Class IV: Incapacitating systemic disease that is a constant threat to life

  • Class V: Moribund patient not expected to survive 24 hours with or without operation


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Dripps-ASA Classification perioperative cardiac mortality and morbidity after noncardiac surgeryShortcomings

  • Subjective

  • Poorly reproducible in certain subsets

    • Elderly

    • Obese

    • Prior MI

    • Mild systemic diseases


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Preoperative Cardiac Assessment perioperative cardiac mortality and morbidity after noncardiac surgeryGoldman Classification

  • Predicts life-threatening cardiac complications or perioperative cardiac death based on presence of preoperative risk factors


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Goldman Multifactorial Index perioperative cardiac mortality and morbidity after noncardiac surgery


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Goldman Multifactorial Index perioperative cardiac mortality and morbidity after noncardiac surgery


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Preoperative Cardiac Assessment perioperative cardiac mortality and morbidity after noncardiac surgery

  • American College of Cardiology Recommendations JACC 1996;27:910-948


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Noncardiac Surgery: General perioperative cardiac mortality and morbidity after noncardiac surgery

  • Indications for further cardiac testing/treatments are the same as those in the nonoperative setting

    • Urgency of noncardiac surgery

    • Patient’s risk factors

    • Specific surgical considerations


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Noncardiac Surgery: General perioperative cardiac mortality and morbidity after noncardiac surgery

  • Preoperative testing should be limited to circumstances in which the results affect patient treatment and outcomes


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Noncardiac Surgery: General perioperative cardiac mortality and morbidity after noncardiac surgery

  • A conservative approach to the use of expensive tests and treatments is recommended


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Preop Cardiac Evaluation: perioperative cardiac mortality and morbidity after noncardiac surgeryConsiderations

  • Type of surgery

  • Functional capacity

  • Clinical history and physical examination


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Noncardiac Surgery: perioperative cardiac mortality and morbidity after noncardiac surgeryHigher Risk Procedures

  • Vascular

  • Prolonged, complicated

    • Thoracic

    • Abdominal

    • Head and neck

  • Total hip replacement


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Preop Cardiac Evaluation perioperative cardiac mortality and morbidity after noncardiac surgery

  • Patients with a low functional capacity (less than 4 Mets) have a worse prognosis than patients with a good functional capacity


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Preop Cardiac Evaluation perioperative cardiac mortality and morbidity after noncardiac surgery

  • Clinical data from a careful history and physical examination are the critical initial steps


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Noncardiac Surgery: Preoperative Clinical Evaluation perioperative cardiac mortality and morbidity after noncardiac surgery

  • Identification of potentially serious cardiac disorders

    • Prior MI

    • Angina pectoris

    • Congestive heart failure

    • Symptomatic arrhythmias

    • Significant valvular heart disease


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Noncardiac Surgery: perioperative cardiac mortality and morbidity after noncardiac surgeryPreoperative Clinical Evaluation

  • Preexisting manifested heart disease

    • Presence

    • Severity

    • Stability

    • Prior treatment


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Noncardiac Surgery: perioperative cardiac mortality and morbidity after noncardiac surgeryPreoperative Clinical Evaluation

  • Always

    • History

    • Physical exam

    • ECG

  • Commonly

    • Echocardiogram/EST

  • Sometimes

    • Cardiac cath/MUGA scan


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Preoperative ECG’s perioperative cardiac mortality and morbidity after noncardiac surgeryRecommended

  • Intrathoracic surgery

  • Intraperitoneal surgery

  • Aortic surgery

  • Neurosurgical procedure

  • Emergency operations


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Preoperative ECG’s perioperative cardiac mortality and morbidity after noncardiac surgeryRecommended

  • History/physical suggesting heart disease

  • Men > 40-45 years old

  • Women > 55 years old

  • Systemic conditions that may be associated with unrecognized cardiac abnormality

  • Medications that can cause cardiac toxicity or ECG changes

  • Patients at risk for major electrolyte abnormalities


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Methods of Assessing Cardiac Risk: perioperative cardiac mortality and morbidity after noncardiac surgeryExercise Stress Testing

  • Provides substantial information about risk of perioperative MI/cardiac death

  • Poor functional capacity, particularly associated with myocardial ischemia predicts high risk

  • Gradient of increasing ischemic risk seen in association with degree of functional capacity, symptoms of ischemia, severity of ischemia, and hemodynamic instability


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Methods of Assessing Cardiac Risk: perioperative cardiac mortality and morbidity after noncardiac surgeryPharmacological Stress Testing

  • Dipyridamole or adenosine with thallium/sestamibi

    • High sensitivity/specificity for perioperative events, especially in intermediate risk group

    • Perioperative ischemic events appear to correlate with the magnitude of ischemia

    • Pharmacological stress testing involving echocardiogram is a viable option


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Methods of Assessing Cardiac Risk: perioperative cardiac mortality and morbidity after noncardiac surgeryResting LV Function

  • LVEF < 35% increases risk of surgery

  • Severe diastolic dysfunction increases risk of surgery

  • Evaluate LV function in presence of CHF

  • Probable evaluation of LV function with history of CHF or dyspnea of unknown etiology


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Management Options after Noninvasive Testing perioperative cardiac mortality and morbidity after noncardiac surgery

  • Intensified medical therapy

  • Cardiac catheterization

    • Cancel or delay surgery

    • Proceed with surgery

    • Coronary revascularization prior to surgery


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Noninvasive Pre-Op Testing perioperative cardiac mortality and morbidity after noncardiac surgery

  • The good news is that noninvasive tests are sensitive to the presence of CAD

  • The bad news is that the positive predictive value is poor because the likelihood of perioperative events is less than 10%


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Methods of Assessing Cardiac Risk: perioperative cardiac mortality and morbidity after noncardiac surgeryCoronary Angiography

  • Appropriate in certain patients at high risk, including those with evidence of significant ischemia or suspicion of left main/three-vessel CAD

  • Indications are similar to those in the nonoperative setting

  • Essential that management with PTCA/CABG is a viable option


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Coronary Angiography perioperative cardiac mortality and morbidity after noncardiac surgeryClass I Indications

  • High-risk results during noninvasive testing

  • Angina pectoris unresponsive to adequate medical therapy

  • Most patients with unstable angina

  • Nondiagnostic or equivocal noninvasive test in a high-risk patient undergoing a high-risk noncardiac surgical procedure


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Coronary Angiography perioperative cardiac mortality and morbidity after noncardiac surgeryClass II Indications

  • Intermediate-risk results during noninvasive testing

  • Nondiagnostic or equivocal noninvasive test in a lower-risk patient undergoing a high-risk noncardiac surgical procedure

  • Urgent noncardiac surgery in a patient convalescing from acute MI

  • Perioperative MI


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Noncardiac Surgery: perioperative cardiac mortality and morbidity after noncardiac surgeryPreoperative CABG

  • Indications are same as those in the nonoperative setting

  • Cardiac risk of CABG often exceeds that of noncardiac surgery

  • Rarely indicated simply to get a patient through the perioperative period


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Noncardiac Surgery: perioperative cardiac mortality and morbidity after noncardiac surgeryPreoperative PTCA

  • No controlled trials

  • Several small observational studies suggest that cardiac death is infrequent in patients who have PTCA prior to noncardiac surgery

  • Indications are similar to those in nonoperative setting


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Noncardiac Surgery: perioperative cardiac mortality and morbidity after noncardiac surgeryEmergency/Immediate Surgery

  • Consultant may function best by making recommendations for perioperative medical management and surveillance

  • Postoperative risk stratification may be appropriate for some patients who have not had such an assessment


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Major Clinical Predictors of Increased Perioperative Cardiovascular Risk

  • Unstable coronary syndromes

    • Recent MI with evidence of ischemic risk

    • Unstable or severe angina

  • Decompensated CHF

  • Significant arrhythmias

    • High-grade AV block

    • Symptomatic ventricular arrhythmias

    • SVT’s with uncontrolled ventricular rate

  • Severe valvular disease


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Noncardiac Surgery: Cardiovascular RiskMajor Clinical Predictors

  • Cancel or delay surgery if surgery is elective

  • Many of these patients are referred for coronary angiography


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Major Clinical Predictors Cardiovascular Risk


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Intermediate Predictors on Increased Perioperative Cardiovascular Risk

  • Mild angina pectoris

  • Prior MI by history or pathological Q-waves

  • Compensated or prior CHF

  • Diabetes mellitus


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Noncardiac Surgery: Cardiovascular RiskIntermediate Clinical Predictors

  • Consideration of functional capacity ( risk increased in patients unable to meet 4-METs of activity )

  • Consideration of level of surgery-specific risk

    • Type of surgery

    • Degree of hemodynamic stress


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Cardiac Event Risk Stratification Cardiovascular Risk

  • High Risk ( > 5% )

    • Emergent major operations, particularly in the elderly

    • Aortic and other major vascular

    • Peripheral vascular

    • Anticipated prolonged surgical procedures associated with large fluid shifts and/or blood loss


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Cardiac Event Risk Stratification Cardiovascular Risk

  • Intermediate Risk ( < 5% )

    • Carotid endarterectomy

    • Head and neck

    • Intraperitoneal and intrathoracic

    • Orthopedic

    • Prostate


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Cardiac Event Risk Stratification: Cardiovascular RiskPatients w/ Intermediate Predictors

  • Patients with moderate/excellent functional capacity can generally undergo intermediate-risk surgery

  • Consider further noninvasive testing

    • Poor functional capacity/intermediate-risk surgery

    • Moderate functional capacity/high-risk surgery


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Intermediate Predictors Cardiovascular Risk


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Minor Predictors of Increased Perioperative Cardiovascular Risk

  • Advanced age

  • Abnormal ECG

  • Rhythm other than sinus

  • Low functional capacity

  • Uncontrolled systemic hypertension


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Noncardiac Surgery: RiskCABG within Five Years

  • Stable clinical status without recurrent symptoms/signs of ischemia

  • Further cardiac testing generally not necessary


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Noncardiac Surgery: RiskStable Angina/CABG > 5 Years

  • Coronary evaluation within past two years?

  • Favorable findings

  • Usually not necessary to repeat testing unless there has been a change in symptoms


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Cardiac Event Risk Stratification: RiskPatients w/ Minor Predictors

  • Noncardiac surgery generally safe

  • Further testing on an individual basis ( patients with several minor clinical predictors facing higher-risk operations, ie vascular surgery )




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Noncardiac Surgery: Hypertension Conditions

  • Severe hypertension should be controlled before surgery when possible

  • Continuation of preoperative antihypertensive treatment through the perioperative period is critical


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Hypertension Conditions

  • Perioperative swings of pressure often occur in hypertensive patients

  • Patients who are adequately treated preoperatively have less marked deviations of blood pressure

  • Surges of BP most common during:

    • Induction

    • Intubation

    • Skin incicision

    • 12 to 24 hours post-op


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Noncardiac Surgery: ConditionsValvular Heart Disease

  • Indications for evaluation/treatment identical to those in nonoperative setting

  • Symptomatic stenotic lesions associated with risk of perioperative CHF/shock

  • Symptomatic regurgitant lesions usually better tolerated perioperatively


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Patients on Anticoagulants Preop Conditions

  • Risk of surgical hemorrhage vs. danger of serious embolization


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Patients on Anticoagulants Preop ConditionsLow Risk for Thromboembolism

  • Discontinue coumadin 3 days preop

  • Restart coumadin postop


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Patients on Anticoagulants Preop ConditionsHigh Risk for Thromboembolism

  • Discontinue coumadin 3 days preop

  • Begin heparin by constant infusion, maintaining PTT 1.5 - 2.5 X control

  • Discontinue heparin 6 - 8 hrs preop

  • Shortly after surgery, restart IV heparin and po coumadin

  • Discontinue heparin infusion when PT is therapeutic

  • Low molecular weight heparin may be used as an alternative agent to IV fractionated heparin


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Higher Risk Conditions

Atrial fibrillation with structural heart disease

Prosthetic mitral valve with or without a fib

Prosthetic aortic valve with a fib

Lower Risk

Atrial fibrillation without structural heart disease

Prosthetic aortic valve with sinus rhythm and normal ejection fraction

Patients on Coumadin PreopRisk for Thromboembolism



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Noncardiac Surgery: artery disease remains complex.Medical Rx of CAD

  • Continuation of preoperative medications into the operative and postoperative period recommended for ischemic protection

  • Beta blockers reduce the incidence of postoperative ischemia


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Beta Blockade in Patients Undergoing Major Vascular Surgery artery disease remains complex.

  • Randomized trial of 112 patients

  • Started on bisoprolol one week prior to surgery

  • Followed for 30 days

  • Cardiac complication rate/placebo: 33.9%

  • Cardiac complication rate/bisoprolol: 3.4%

    Poldermans D. NEJM 1999;341:1789-1794


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Noncardiac Surgery: artery disease remains complex.Intraoperative Nitroglycerin

  • Insufficient data on use of prophylactic intraoperative nitroglycerin

  • Vasodilatory properties when combined with anesthetic agent may lead to hypotension and ischemia

  • Hemodynamic effects of other agents needs to be considered


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Noncardiac Surgery: artery disease remains complex.Congestive Heart Failure

  • Patients with preop CHF are at increased risk for postoperative exacerbation

  • Treatment of manifestations of heart failue before surgery may reduce complication rates

  • Overdiuresis may lead to hypotension

  • New onset of CHF in patients without prior history suggests postop MI


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Noncardiac Surgery: artery disease remains complex.Arrhythmias & Conduction Abnormalities

  • Careful evaluation for underlying cardiopulmonary disease, drug toxicity, or metabolic abnormality

  • Indications for antiarrhythmic therapy and cardiac pacing identical to those in the nonoperative setting


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Noncardiac Surgery: artery disease remains complex.Evaluation of Pulmonary Function

  • Patients scheduled for thoracic surgery

  • Patients scheduled for upper abdominal surgery

  • Patients w/ history of heavy smoking/cough

  • Obese patients

  • Patients > 70 years of age

  • Patients with pulmonary disease

  • Value of routine PFT’s remains controversial NEJM 1999;340:937


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PFT’s: Indicators of High Risk Morbidity/Mortality artery disease remains complex.

  • Spirometric

    • Maximal breathing capacity < 50% predicted

    • FEV1 < 2.0 liters

  • Arterial Blood Gases

    • Arterial PCO2 > 45 mm/hg

    • Hypoxemia not reliable


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Noncardiac Surgery: artery disease remains complex.Anesthetic Agent

  • Choice should be left to the discretion of the anesthesia care team

  • Opiod-based anesthetics popular because of cardiovascular stability, but high doses result in postoperative ventilation

  • All inhalational agents have cardiovascular effects


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Noncardiac Surgery: pain will be associated with markedly increased cardiac demandsAnesthetic Agent

  • Neuraxial Techniques

    • Spinal and epidural anesthesia

    • Cause sympathetic blockade

    • Infrainguinal procedures associated with mininal hemodynamic changes

    • Abdominal procedures may result in more profound effects: hypotension/reflex tachycardia


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Noncardiac Surgery: pain will be associated with markedly increased cardiac demandsAnesthetic Agent

  • Monitored Anesthesia

    • Local anesthesia supplemented by intravenous sedation/analgesia

    • Failure to produce complete anesthesia may lead to increased stress response producing myocardial ischemia


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Noncardiac Surgery: pain will be associated with markedly increased cardiac demandsPerioperative Pain Management

Patient-controlled intravenous and/or epidural analgesia

  • Reduces severity and duration of postoperative pain

  • Reduction in postoperative catecholamine surges and hypercoagulability

  • Theoretically may decrease myocardial ischemia


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Noncardiac Surgery: pain will be associated with markedly increased cardiac demandsPulmonary Artery Catheters

  • Patients most likely to benefit

    • Recent MI complicated by CHF

    • Patients with significant CAD undergoing procedures associated with significant hemodynamic stress

    • Patients with systolic/diastolic dysfunction, cardiomyopathy, and valvular disease undergoing high-risk operations


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Noncardiac Surgery: pain will be associated with markedly increased cardiac demandsPostop Ischemia

  • Myocardial ischemia more common, more severe in early postoperative phase

  • Infarction is frequently silent

  • Non-Q MI often occurs on the first or second postoperative days

  • Q-wave MI often occurs on the second to fourth postoperative days

  • CHF/pulmonary edema commonly occurs on postop day 2 or later


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Noncardiac Surgery: pain will be associated with markedly increased cardiac demandsSurveillance for Perioperative MI

  • Few studies have examined the optimal method

  • Indicators of ischemia

    • Clinical symptoms

    • ECG changes

    • Elevation of cardiac enzymes


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Noncardiac Surgery: pain will be associated with markedly increased cardiac demandsSurveillance for Perioperative MI

  • Patients without known CAD: surveillance should probably be restricted to patients with signs of cardiovascular dysfunction

  • Patients with known or suspected CAD undergoing high-risk procedures: baseline, then serial ECG’s recommended

  • Cardiac enzymes reserved for patients with evidence of cardiovascular dysfunction


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Noncardiac Surgery: pain will be associated with markedly increased cardiac demandsST-Segment Monitoring

  • ST changes indicating myocardial ischemia are strong predictors of perioperative MI in patients at high clinical risk

  • Postoperative ischemia is a significant predictor of long-term MI/cardiac death

  • ST depression in low-risk patients may be a nonspecific finding


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Noncardiac Surgery: pain will be associated with markedly increased cardiac demandsPostop Rx and Long-Term Management

  • Assessment and management of modifiable risk factors for cardiovascular disease

  • May be first opportunity for a systematic cardiovascular evaluation in many patients

  • Patients who experience repetitive postop myocardial ischemia and/or myocardial infarction are at substantially increased risk


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