Evaluation of Cardiac Patient

1. Evaluation of Cardiac Patient Wayne E. Ellis, Ph.D., CRNA

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3. Statistics 30 million noncardiac surgeries annually 3 million individuals with known or probable coronary artery disease 50,000 (1.7%) perioperative MI’s annually 10,000 - 20,000 deaths per year (20 - 40 % mortality) 25 - 50 % of all perioperative deaths annually Costs > $ 500 million per year WE Ellis

4. Recent Myocardial Infarction Less than three months Patient < 70 years of age Location of surgery Duration of surgery Poor LV function CHF Enlarged heart Arrhythmias Increased risk of morbidity and MORTALITY WE Ellis

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6. Challenge of Anesthesia Adequately evaluate the patient 5 – 7 minutes to find out every thing about the patient Provide adequate anesthesia Prevent myocardial injury Maximize postoperative pain management WE Ellis

7. Anesthesia Goals Balance supply and demand Control heart rate Normal to slow range Maintain CPP Prevent hypotension Prevent increased LVEDP Optimize arterial oxygen and carbon dioxide status Keep patient normothermic Higher threshold for transfusion WE Ellis

8. Most Commonly Seen Events Perioperative MI Pulmonary Edema Congestive Heart Failure Arrhythmias Thromboembolism WE Ellis

9. What is a cardiac risk assessment? Group of tests and health factors Proven to indicate your chance of having a coronary event Refined to indicate the degree of risk Slight Moderate High WE Ellis

10. Risk Stratification The Goldman index Useful in predicting cardiac events in an unselected, random group of patients Does not work well when applied to subgroups, such as all those with known heart disease Type and extent of surgery anticipated needs to be taken into account when one is interpreting the results of the Goldman index Functional status If patient can walk up stairs while carrying a load (functional status class I and II) Low Goldman index No known cardiac disease Very low risk of cardiac complications WE Ellis

11. Risk Stratification Electrocardiography Ischemia on a resting ECG is suggestive of a worse outcome Exercise tolerance appears to be more important than ECG changes in predicting outcomes If functional status is good (class I or II) Graded Exercise Test (GXT) need not be done Reserve GXT for recent-onset chest pain and unclear functional status WE Ellis

12. Risk Stratification Echocardiography Need an echocardiogram even if not having surgery Murmurs that have not been previously evaluated CHF of unknown cause (diastolic versus systolic versus valvular, etc.) Stress echocardiography Used as a replacement for the GXT Radionuclide ventriculography determined ejection fraction Has not been shown to be useful in determining risk for infarction perioperatively this type of datum is taken into account with clinical measures in the Goldman index (S3 gallop, JVD) and in functional status (class) WE Ellis

13. Risk Stratification Thallium scanning Highly sensitive at selecting those who will have postoperative cardiac problems Specificity is a problem (53% to 80%) unless restricted to a high-risk group Thallium scanning should be restricted to those individuals who cannot exercise Functional status of these patients cannot be determined Risk cannot be determined by clinical criteria WE Ellis

14. Risk Stratification History of MI <3 weeks has 25% mortality Urgent procedure only At 3 months 10% mortality Semi-urgent procedures At 6 months 5% mortality Elective At 1 year, same risk as asymptomatic patient with cardiac disease. Mark A. Graber, MD; Departments of Family Medicine and Emergency Medicine; University of Iowa College of Medicine; 2004 WE Ellis

15. Risk of Reinfarction WE Ellis

16. Risk Factors for Reinfarction The differences between the studies Monitoring ICU stay Can apply these interventions to all of your patients? $$$$$$$

17. Mortality Mortality due to reinfarction: about 30% (2001) Historically cited as 50 - 80% Current Practices - dependent on: Age of 1st MI in relation to current surgery DM Monitoring

18. Perioperative Predictors Recent MI < 1 Month (Morgan & Mikhail) < 6 months Current CHF Only consistent predictors of perioperative outcome Operative Predictor Operative site Potential/actual blood loss WE Ellis

19. Assessment and Evaluation WE Ellis

20. How does one decide on which test? History and Physical Risk assessment Low Medium High WE Ellis

21. Protocol Step 1 Evaluate urgency of noncardiac surgery Emergency requires surgery regardless of risk Step 2 Noninvasive cardiac testing not required Coronary revascularization in past 5 years Must be stable and no recurrent symptoms or signs Coronary evaluation in last 2 years Evaluation must have been favorable and adequate No new symptoms or signs since evaluation WE Ellis

22. Protocol Step 3 Indications for noninvasive cardiac testing Major patient risk factors Cardiac evaluation needed in all cases Intermediate Risk Indications for cardiac evaluation Decreased functional capacity Surgery with higher cardiovascular risk Minor risk Indications for cardiac evaluation on individual basis Consider in decreased functional capacity WE Ellis

23. Assessment of Risk Factors May have a normal physical Family history Diabetes Cigarette smoking Hypertension WE Ellis

24. Perioperative Estimation of Risk Recent preoperative MI average 8% reinfarction if within 3 months Optimal preparation Invasive Monitoring Without monitoring, ?adequate preparation > 30% Age >65 < 70 10 fold increased risk > 70 WE Ellis

25. What is included in risk assessment? Most important indicators for cardiac risk Personal health history Age Hereditary factors Weight Smoking Blood pressure Exercise history Diabetes WE Ellis

26. Greatest Risk Extensive 3-vessel disease Left main disease Ventricular dysfunction Residual ischemia remaining from previous MI Mortality rates exceed 50% WE Ellis

27. Hypertension Regardless of perioperative control Accentuated hypotensive response to induction Exaggerated hypertensive response to endogenous and exogenous catecholamines Difficult control during emergence even when not intubated WE Ellis

28. What is included in risk assessment? Lipid profile Most important blood test for risk assessment Other tests Non-invasive tests EKG stress test Thallium stress test EKG CT scan Echocardiogram Invasive tests Arteriogram Cardiac catheterization. WE Ellis

29. How is the lipid profile used? Measures cholesterol, triglycerides, HDL (“good” cholesterol), and LDL (“bad” cholesterol) Triglycerides Major form of fat found in the body Function is to provide energy for the cells Desirable ranges for the components Cholesterol <200 mg/dL (5.18 mmol/L) HDL-cholesterol > 40 mg/dL (1.04 mmol/L) LDL-cholesterol <100 mg/dL* (2.59 mmol/L) Triglycerides <150 mg/dL (1.70 mmol/L) If any or all of the results are significantly outside these ranges, the risk of a cardiac event is significantly increased WE Ellis

30. What other tests are used? Serum homocysteine Amino acid that comes from the normal breakdown of proteins in the body and appears to be a better test than cholesterol for predicting heart disease, stroke, and reduced blood flow to the hands and feet High-sensitivity C-reactive protein Hs-CRP Measured on apparently healthy patients to determine if they are at risk for a coronary even Even if their lipid levels are normal or borderline elevated. WE Ellis

31. What other tests are used? Lipoprotein A, Lp(a) Lipoprotein consisting of an LDL molecule with another protein (Apolipoprotein (a)) attached to it. Lp(a) is similar to LDL but does not respond to typical strategies to lower LDL such as diet, exercise, or most lipid lowering drugs Level of Lp(a) appears to be genetically determined and not easily altered Presence of a high level of Lp(a) may be used to identify individuals who might benefit from more aggressive treatment of other risk factors WE Ellis

32. History - Do a good one!!! • Stability of angina • NYHA • Class I: Mild angina without impairment • Class IV: Angina at rest • Exercise tolerance! • Ventricular function • Associated cardiovascular diseases • Medication WE Ellis

33. Physical exam • Vital signs • Cardiac exam • PMI • Gallops • S4: HTN, S3: increased LVEDP • Apical systolic murmur • Papillary muscle dysfunction • Precordial bulge • Other signs of LV function • JVD, pulmonary signs • Pitting Edema, Pulses, Vascular Access WE Ellis

34. Physical Signs Heart Sounds S3 or S4 New onset mitral regurgitation Jugular distention Jugular pulsations Chest sounds Rales WE Ellis

35. Cardiac stethoscope Combination bell and diaphragm chestpiece Low frequency abnormal heart sounds can only be heard with a bell Held lightly against the skin No after-impression is seen Too firm a pressure on the bell causes it to act as a diaphragm

36. Cardiac Stethoscope High frequency heart sounds are heard with diaphragm Held firmly enough against the skin After-irnpression is seen

37. Design of Stethoscope Acoustically sealed and is durable in design Scopes that you assemble yourself are not sealed at the junctions Air leaks will lower the quality of acoustical transmission M internal spring prevents kinking of the "V.' tubing Help the tubing wear longer

38. Sites of Auscultation Left Lateral Sternal Border Formerly known as the tricuspid area Fourth intercostal space left of the sternum Tricuspid component of the first heart sound is most audible here

39. Sites of Auscultation Apex or mitral area Fifth intercostal space on the midclavicular line Mitral component of the first heart sound is loudest here

40. Sites of Auscultation Base Left, or the pulmonic area Second intercostal space to the left of the sternum Pulmonic component of the second heart sound audible here

41. Sites of Auscultation Base Right, or the aortic area Second intercostal space to the right of the sternum Aortic component of the second heart sound is prominent here

42. Position for Auscultation Quiet room, free from distractions Diaphragm or bell side of the stethoscope make contact with the skin Full upper body disrobing Examine the person in at least three positions Sitting Supine Left lateral recumbent

43. Order of Auscultation Diaphragm First Heart Sound at all four locations Start at apex and move clockwise through all four sites Bell Begin at same location and listen for any abnormalities

44. HEART MURMURS Grade I The faintest murmur you can hear Often not heard at first Grade 2 Faint but heard without difficulty Grade 3 Soft, but louder than grade 2 Grade 4 loud, but 1ess loud than grade 3 Grade 5 Loud. but not heard if stethoscope is lifted just off the chest Grade 6 Maximum loudness, heard even if stethoscope is lifted from the chest

45. EXAMINATION A complete cardiac exam includes history taking, physical examination and indicated supplementary procedures, e.g., EKG, fluoroscopy, cardiac catheterization, etc.

46. EXAMINATION The examination is begun with the patient sitting. Initial observations are made and the patient then reclines with the arms at the sides and blood pressure measured Examination of the extremities, neck and precordium are carried out in that order Blood pressure Palpatory method Auditory method

47. EXAMINATION The highest level at which sounds are heard is the systolic pressure and the point of complete disappearance of sound is considered the best index of diastolic pressure.

48. EXAMINATION Measure the pressure over the thighs. Normal range: Systolic 95-140 mm Hg Diastolic 60-90 mm Hg

49. EXAMINATION Pulse pressure is the difference between systolic and diastolic pressures Mean pressure - Divide pulse pressure by 3 and add this to the diastolic pressure Common sources of error: Discrepancies between cuff size and limb size Loose application of cuff Anxiety in the patient Failure to recognize an auscultatory gap

50. EXAMINATION Hypertension is persistent elevation of systemic blood pressure >140/90 Widened pulse pressure common to all conditions producing an increased stroke volume, e.g., fever, anemia, thyrotoxicosis Hypotension is when the pressure is 95/60, shock may result from decreased cardiac output, peripheral resistance, blood volume