p.9
Preoperative Cardiac Evaluation
What does 1 MET represent in terms of activities?
Basic self-care activities like eating, dressing, or using the toilet.
p.13
Perioperative Management of Antiplatelet Therapy
What should be done 3-6 months after DES implantation regarding DAPT?
Discontinue DAPT; surgery may be considered.
p.13
Perioperative Management of Antiplatelet Therapy
What is the guideline for BMS surgery ≥30 days post-implantation?
Class I: Safe for non-cardiac surgery.
p.2
Pathophysiology of Perioperative MI
What factors can cause myocardial oxygen demand to increase?
Sympathetic hyperactivity, postoperative pain, withdrawal of β-blockers, hypovolemia, cardiac decompensation, systemic vasodilation, increased heart rate/arrhythmia.
p.14
Active Cardiac Conditions Requiring Evaluation
What is a recent myocardial infarction (MI) timeframe that requires evaluation before non-cardiac surgery?
Recent MI within 90 days.
p.3
Revised Cardiac Risk Index (RCRI)
What is not counted in the RCRI unless other criteria for ischemic heart disease are present?
Prior coronary revascularization procedures.
p.2
Revised Cardiac Risk Index (RCRI)
What are the independent predictors of major cardiac complications in RCRI?
High-risk type of surgery and history of ischemic heart disease.
p.11
Risk Stratification for Surgical Procedures
What should be considered for intermediate-risk surgery with one or more clinical risk factors?
Noninvasive stress testing.
p.14
Active Cardiac Conditions Requiring Evaluation
What NYHA functional class indicates decompensated heart failure (HF) requiring evaluation?
NYHA functional class IV.
p.6
Active Cardiac Conditions Requiring Evaluation
What was the outcome of early intervention with CRT-D in the MADIT-CRT trial?
Associated with a significant long-term survival benefit in patients with mild heart-failure symptoms.
p.13
Perioperative Management of Antiplatelet Therapy
What is the recommendation for surgery <30 days after BMS implantation?
Class III: Delay surgery.
p.2
Pathophysiology of Perioperative MI
What factors affect subendocardial oxygen supply?
Hypotension, myocardial wall stress, coronary vasoconstriction, anemia, hypoxemia.
p.9
Preoperative Cardiac Evaluation
What should be done for patients according to GDMT or alternate strategies?
Proceed to surgery or consider noninvasive treatment and palliation.
p.9
Preoperative Cardiac Evaluation
What is done if the pharmacologic stress test is abnormal?
Coronary Angiography (CAG) is performed to delineate coronary anatomy and guide revascularization.
p.7
Perioperative Management of Antiplatelet Therapy
What should be considered regarding aspirin discontinuation?
Discontinuation should be considered in patients where hemostasis is anticipated to be difficult to control during surgery.
p.12
Perioperative Management of Antiplatelet Therapy
What should be continued before coronary artery bypass grafting (CABG)?
Single antiplatelet therapy (SAPT).
p.12
Perioperative Management of Antiplatelet Therapy
What factors should be considered when managing aspirin in the perioperative period?
Perioperative bleeding risk versus thrombotic complications.
p.4
Risk Stratification for Surgical Procedures
What types of surgery are classified as intermediate risk?
Intraperitoneal and intrathoracic surgery, Carotid endarterectomy, Head and neck surgery, Orthopedic surgery, Prostate surgery.
p.1
Pathophysiology of Perioperative MI
What is the mechanism behind Type 1 MI?
Rupture of a coronary plaque leads to platelet aggregation and thrombus formation.
p.8
Preoperative Cardiac Evaluation
What is the recommendation for patients with moderate or greater functional capacity?
No further testing required and proceed to surgery.
p.11
Perioperative Management of Antiplatelet Therapy
What should be done if noninvasive stress test results show no/mild/moderate stress-induced ischemia?
Proceed with planned surgery.
p.1
Pathophysiology of Perioperative MI
What physiological changes are associated with unstable coronary plaques?
Sympathetic hyperactivity, hemodynamic instability, and coronary vasoconstriction.
p.2
Types of Myocardial Infarction
What are the two main causes of Acute Coronary Thrombosis?
Plaque rupture and plaque erosion.
p.5
Risk Stratification for Surgical Procedures
Which surgeries are considered low risk (<1%)?
Superficial surgery, breast surgery, dental surgery, thyroid surgery, eye surgery, reconstructive surgery, carotid asymptomatic surgery, minor gynecological surgery, minor orthopedic surgery, minor urological surgery, endoscopic procedures, cataract surgery.
p.3
Revised Cardiac Risk Index (RCRI)
What is a current complaint that may indicate myocardial ischemia?
Chest pain considered secondary to myocardial ischemia.
p.7
Perioperative Management of Antiplatelet Therapy
What is the significance of the POISE-2 trial?
It supports the Class IIb recommendation for the continuation of aspirin.
p.3
Revised Cardiac Risk Index (RCRI)
What symptoms indicate a history of heart failure?
Dyspnea > II, pedal edema, orthopnea, JVP.
p.2
Revised Cardiac Risk Index (RCRI)
What types of surgeries are considered high-risk according to RCRI?
Vascular surgery and any open intraperitoneal or intrathoracic procedures.
p.11
Revised Cardiac Risk Index (RCRI)
What does RCRI stand for?
Revised Cardiac Risk Index.
p.14
Active Cardiac Conditions Requiring Evaluation
What types of significant arrhythmias require evaluation before non-cardiac surgery?
High-grade atrioventricular block, Mobitz II block, third-degree block, symptomatic ventricular arrhythmias, and uncontrolled supraventricular arrhythmias.
p.10
Active Cardiac Conditions Requiring Evaluation
What are possible options if coronary artery intervention is needed?
Proceed for coronary artery intervention with dual antiplatelet therapy if the surgical procedure can be delayed, or proceed directly to operation with optimal medical therapy if delay is impossible.
p.10
Risk Stratification for Surgical Procedures
What recommendations are made for low-risk surgical procedures?
Identify risk factors and provide recommendations on lifestyle and medical therapy according to ESC Guidelines.
p.5
Risk Stratification for Surgical Procedures
Which surgeries fall under intermediate risk (1%-5%)?
Intraperitoneal surgery, splenectomy, hiatal hernia repair, cholecystectomy, carotid symptomatic surgery, peripheral arterial angioplasty, endovascular aneurysm repair, head and neck surgery, major neurological or orthopedic surgery, major urological or gynecological surgery, renal transplant, non-major intrathoracic surgery.
p.7
Perioperative Management of Antiplatelet Therapy
What does Class IIb recommendation for aspirin indicate?
Continuation of aspirin may be considered in the peri-operative period based on the risk of bleeding and thrombosis.
p.14
Active Cardiac Conditions Requiring Evaluation
What underlying conditions are associated with Atrial Fibrillation with Fast Ventricular Rate (AF with FVR)?
Rheumatic Heart Disease (RHD) and Mitral Stenosis (MS).
p.4
AUB-HAS2 Cardiovascular Risk Index
What are the three risk groups identified by the AUB-HAS2 index for patients undergoing noncardiac surgery?
Low risk (score 0-1), Intermediate risk (score 2-3), High risk (score >3).
p.1
Perioperative Myocardial Infarction (MI)
When is the most common time for perioperative myocardial infarction (MI) to occur in non-cardiac surgery?
24-48 hours after surgery.
p.1
Types of Myocardial Infarction
What is the most common type of MI during the perioperative period?
Type 2 MI (demand supply mismatch).
p.7
Perioperative Management of Antiplatelet Therapy
What is the recommendation for patients already on aspirin?
Peri-operative continuation of aspirin may be considered. (Class IIb)
p.14
Active Cardiac Conditions Requiring Evaluation
What symptoms indicate symptomatic mitral stenosis that requires evaluation?
Progressive dyspnea on exertion, exertional presyncope, or heart failure.
p.8
Preoperative Cardiac Evaluation
What is the next step if further testing is deemed necessary for patients with poor functional capacity?
Conduct pharmacologic stress testing.
p.13
Perioperative Management of Antiplatelet Therapy
What is the recommendation for surgery within <3 months after Drug-Eluting Stent (DES) implantation?
Class III: Harm — Delay surgery.
p.9
Preoperative Cardiac Evaluation
What is recommended for patients with poor or unknown functional capacity unable to do physiological stress testing?
Pharmacologic stress testing (MPI) is recommended.
p.13
Perioperative Management of Antiplatelet Therapy
What is the recommendation for surgery ≥6 months after DES implantation?
Discontinue DAPT; Class I: Proceed with surgery.
p.9
Preoperative Cardiac Evaluation
What activities can be performed at 4 METs?
Light housework, climbing stairs, walking at 4 mph, and moderate recreational activities.
p.8
Risk Stratification for Surgical Procedures
What is the recommendation for low-risk patients (<1%) in perioperative cardiac assessment?
No further testing and proceed to surgery.
p.4
Risk Stratification for Surgical Procedures
What types of surgery are classified as high risk according to the risk stratification?
Aortic and other major vascular surgery, Peripheral vascular surgery.
p.1
Types of Myocardial Infarction
What causes Type 1 myocardial infarction (MI)?
Plaque rupture (spontaneous MI).
p.8
Preoperative Cardiac Evaluation
What is the functional capacity threshold for further testing in elevated-risk patients?
Moderate or greater (≥4 METs).
p.11
Preoperative Cardiac Evaluation
When should noninvasive testing be considered?
Prior to any surgical procedure for patient counseling or change of perioperative management.
p.11
Perioperative Management of Antiplatelet Therapy
How long after balloon angioplasty can surgery be performed?
>2 weeks after intervention.
p.8
Active Cardiac Conditions Requiring Evaluation
What should be done after coronary angiography if indicated?
Coronary revascularization according to existing guidelines.
p.6
Perioperative Management of Antiplatelet Therapy
What was the outcome of spironolactone in the TOPCAT trial?
Significantly reduced the incidence of the primary composite in patients with heart failure and preserved ejection fraction.
p.9
Preoperative Cardiac Evaluation
What activities are associated with >10 METs?
Strenuous sports such as swimming, singles tennis, football, basketball, or skiing.
p.13
Active Cardiac Conditions Requiring Evaluation
What does the ACC National Database Registry define as recent MI?
Occurs within 7 days to 1 month.
p.2
Revised Cardiac Risk Index (RCRI)
What is the most common scoring method for risk stratification in non-cardiac surgery?
Revised Cardiac Risk Index (RCRI).
p.14
Active Cardiac Conditions Requiring Evaluation
What are the unstable coronary syndromes that require evaluation before non-cardiac surgery?
Unstable or severe angina (CCS class III or IV) and recent MI <60 days.
p.10
Preoperative Cardiac Evaluation
What does the consultant provide recommendations on?
Perioperative medical management, surveillance for cardiac events, and continuation of chronic cardiovascular medical therapy.
p.12
Perioperative Management of Antiplatelet Therapy
What type of inhibitor is Ticagrelor?
A reversible inhibitor of the P2Y12 receptor.
p.12
Perioperative Management of Antiplatelet Therapy
What type of inhibitor is Prasugrel?
An irreversible inhibitor.
p.8
Active Cardiac Conditions Requiring Evaluation
What is the next step if pharmacologic stress testing is abnormal?
Coronary angiography (CAG) to delineate coronary anatomy.
p.6
Guidelines for Cardiac Assessment in Non-Cardiac Surgery
What was the outcome of administering aspirin before surgery according to the POISE-2 trial?
Had no significant effect on the rate of death or nonfatal myocardial infarction.
p.6
Perioperative Management of Antiplatelet Therapy
What was the outcome of renal artery denervation in the SIMPLICITY HTN-3 trial?
Did not show a significant reduction of systolic blood pressure in patients with resistant hypertension.
p.7
Perioperative Management of Antiplatelet Therapy
What is the recommendation for peri-operative continuation of statins?
It is recommended to continue statins, favoring those with a long half-life or extended-release formulation. (Class I)
p.5
Risk Stratification for Surgical Procedures
What surgeries are classified as high risk (>5%)?
Aortic and major vascular surgery, open lower limb revascularization or amputation, duodeno-pancreatic surgery, liver resection, bile duct surgery, esophagectomy.
p.8
Preoperative Cardiac Evaluation
What should be done if Acute Coronary Syndrome (ACS) is present?
Evaluate and treat according to GDMT.
p.14
Active Cardiac Conditions Requiring Evaluation
What symptom indicates a patient with symptomatic severe mitral stenosis (MS) may not be able to undergo non-cardiac surgery?
Patient is not able to lie down.
p.10
Preoperative Cardiac Evaluation
What dictates the strategy for perioperative cardiac management?
Patient- or surgical-specific factors.
p.4
Risk Stratification for Surgical Procedures
What types of surgery are classified as low risk?
Endoscopic procedures, Superficial procedures, Cataract surgery, Breast surgery, Ambulatory surgery.
p.1
Pathophysiology of Perioperative MI
What primarily causes Type 2 myocardial infarction (MI)?
Prolonged imbalance between myocardial oxygen supply and demand in the setting of coronary artery disease (CAD).
p.8
Preoperative Cardiac Evaluation
What should be done if a patient has poor or unknown functional capacity (<4 METs)?
Determine if further testing will impact decision making or perioperative care.
p.1
Perioperative Myocardial Infarction (MI)
What are the common events occurring in patients undergoing non-cardiac surgery?
Atrial fibrillation (AF) and perioperative myocardial infarction (MI).
p.4
AUB-HAS2 Cardiovascular Risk Index
How can the AUB-HAS2 cardiovascular risk index be utilized?
By busy physicians in clinic or nurses in preadmission units to quickly stratify cardiovascular risk.
p.11
Perioperative Management of Antiplatelet Therapy
When can surgery be performed after bare-metal stent placement?
≥4 weeks after stent placement.
p.12
Perioperative Management of Antiplatelet Therapy
What should be done if it is 30 days or more since BMS implantation?
Proceed with surgery (Class I).
p.5
Revised Cardiac Risk Index (RCRI)
What type of surgery is classified as high risk according to RCRI criteria?
Intraperitoneal/intrathoracic surgery.
p.6
Perioperative Management of Antiplatelet Therapy
What should be discontinued before surgery?
Clopidogrel and Ticagrelor.
p.4
AUB-HAS2 Cardiovascular Risk Index
How does the performance of the AUB-HAS2 index compare to the Revised Cardiac Risk Index?
The AUB-HAS2 index is superior to the Revised Cardiac Risk Index.
p.8
Risk Stratification for Surgical Procedures
What should be done for elevated-risk patients?
Further clinical management based on risk stratification.
p.8
Guidelines for Cardiac Assessment in Non-Cardiac Surgery
What factors should be considered for non-cardiac surgery?
Emergency vs. elective surgery.
p.14
Active Cardiac Conditions Requiring Evaluation
Should asymptomatic severe aortic stenosis or symptomatic mitral stenosis undergo extensive evaluation before non-cardiac surgery?
No, they should be sent for non-cardiac surgery without much evaluation.
p.7
Perioperative Management of Antiplatelet Therapy
When should pre-operative initiation of statin therapy be considered?
In patients undergoing vascular surgery, ideally at least 2 weeks before surgery. (Class IIa)
p.9
Preoperative Cardiac Evaluation
What is the first step in preoperative cardiac risk evaluation?
Determine if the surgery is urgent.
p.8
Risk Stratification for Surgical Procedures
What is the next step if ACS is not present?
Estimate perioperative risk of MACE based on combined clinical/surgical risk.
p.7
Guidelines for Cardiac Assessment in Non-Cardiac Surgery
What is the first step in the 2014 ACC/AHA guideline for perioperative cardiac assessment?
Identify if the patient has known risk factors for CAD.
p.3
Revised Cardiac Risk Index (RCRI)
What conditions are included in the history of cerebrovascular disease?
Transient Ischemic Attack (TIA) or Stroke.
p.3
Revised Cardiac Risk Index (RCRI)
What type of diabetes is considered a risk factor in RCRI?
Diabetes mellitus requiring treatment with insulin.
p.14
Active Cardiac Conditions Requiring Evaluation
What defines severe aortic stenosis that requires evaluation?
Mean pressure gradient >40 mm Hg, aortic valve area <1.0 cm², or symptomatic.
p.12
Perioperative Management of Antiplatelet Therapy
What type of inhibitor is Clopidogrel?
An irreversible inhibitor.
p.11
Perioperative Management of Antiplatelet Therapy
What is recommended for extensive stress-induced ischemia?
Individualized perioperative management considering the potential benefits and adverse outcomes.
p.4
AUB-HAS2 Cardiovascular Risk Index
What is the significance of the AUB-HAS2 index in surgical settings?
It provides a simple and comprehensive measure for cardiovascular risk stratification.
p.12
Perioperative Management of Antiplatelet Therapy
What is the recommendation for surgery if it is less than 30 days since Bare-Metal Stent (BMS) implantation?
Delay surgery (Class III: Harm).
p.13
Perioperative Management of Antiplatelet Therapy
What is the risk associated with surgery 3-6 months after DES implantation?
Delayed surgery risk is greater than stent thrombosis risk.
p.8
Revised Cardiac Risk Index (RCRI)
What methods are used for risk assessment in perioperative cardiac evaluation?
RCRI (Revised Cardiac Risk Index) and AUB-HAS2 Score.
p.7
Guidelines for Cardiac Assessment in Non-Cardiac Surgery
What should be done if emergency surgery is required?
Proceed with clinical risk stratification and then proceed to surgery.
p.7
Perioperative Management of Antiplatelet Therapy
What is the recommendation for patients already on statins?
Peri-operative continuation of statin therapy is recommended. (Class I)
p.3
Revised Cardiac Risk Index (RCRI)
What serum creatinine level is a risk factor in RCRI?
Preoperative serum creatinine > 2.0 mg/dL.
p.11
Preoperative Cardiac Evaluation
What additional evaluations may be considered for patients with 2 or fewer cardiac risk factors?
Rest echocardiography and biomarkers for LV function.
p.10
Risk Stratification for Surgical Procedures
What should be determined in Step 3 of the evaluation?
The risk of the surgical procedure.
p.10
Preoperative Cardiac Evaluation
What should be considered for patients with known ischemic heart disease before surgery?
Initiation of a titrated low-dose beta blocker regimen.
p.10
Active Cardiac Conditions Requiring Evaluation
What should be done if active or unstable cardiac conditions are present?
Discuss treatment options in a multidisciplinary team.
p.10
Risk Stratification for Surgical Procedures
What may be considered for patients with one or more clinical risk factors?
Preoperative baseline ECG to monitor changes during the perioperative period.
p.11
Perioperative Management of Antiplatelet Therapy
When can surgery be performed after old-generation drug-eluting stents?
Within 12 months after intervention.
p.12
Perioperative Management of Antiplatelet Therapy
What is the mnemonic for stopping antiplatelet medications before surgery?
TCP (Ticagrelor, Clopidogrel, Prasugrel) - 3, 5, 7 days.
p.10
Preoperative Cardiac Evaluation
What should be considered for patients undergoing vascular surgery?
Initiation of statin therapy.
p.1
Pathophysiology of Perioperative MI
What are the hemodynamic instabilities associated with unstable coronary plaques?
Tachycardia and hypertension.
p.11
Perioperative Management of Antiplatelet Therapy
When can surgery be performed after new-generation drug-eluting stents?
Within 6 months after intervention.
