Outpatients with Huge Heart History.


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Layout. Perioperative Cardiovascular EvaluationCase PresentationUpdate on Perioperative Beta BlockadePatients with StentsCardiac Rhythm Management Devices. ACC/AHA Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac SurgeryBorn: 1996Reborn: 2002Revised: 2007. Changes in the 2007 Guidelines.
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Outpatients with Significant Cardiac History Tamas Szabo, MD, PhD Ralph H. Johnson VAMC Medical University of South Carolina South Carolina Society of Anesthesiologists Annual Meeting June 5, 2010

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Outline Perioperative Cardiovascular Evaluation Case Presentation Update on Perioperative Beta Blockade Patients with Stents Cardiac Rhythm Management Devices

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ACC/AHA Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery Born: 1996 Reborn: 2002 Revised: 2007

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Changes in the 2007 Guidelines Major Predictors: Active Cardiac Conditions Intermediate Predictors: Revised Cardiac Risk Index Minor Predictors: their nearness is not a sign for further workup (but rather may prompt a higher suspicion of CAD) Functional Capacity: expanded accentuation

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Active Cardiac Conditions Condition Examples Unstable coronary syndromes Unstable/extreme angina Recent MI (1 week-1 month) Decompensated HF (NYHA IV.) Significant arrhythmias Newly perceived ventricular tachycardia Symptomatic ventricular arrhythmias Symptomatic bradycardia Supraventricular arrhythmias (>100/min) Third degree AVB Mobitz II. AVB Severe valvular disease Severe AS (AVA<1 cm 2 , mean inclination >40 mmHg Symptomatic MS (DOE, HF, syncope)

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Revised Cardiac Risk Index (Lee) Prediction of heart danger for stable patients experiencing elective major noncardiac surgery. Computer aided design (h/0 MI, NTG-use, CP, q-waves, +stress test) CHF (h/o pneumonic edema, PND) Cerebrovascular infection (stroke, TIA) Diabetes (on insulin) Creatinine > 2 mg/dl

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Validation of the Lee-score Dutch dataset with 108,593 noncardiac operations. 1 point each for CAD, CHF, CVD, IDDM, Cr >2, High-chance surgery. 0.5% Total cardiovascular passings 543 (0.5%).

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Functional Capacity

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Cardiac Risk Stratification for Noncardiac Surgeries Risk Stratification Examples Vascular (heart hazard > 5%) Aortic/Major vascular surgery Peripheral vascular surgery Intermediate (1-5%) Intraabdominal/Intrathoracic surgery Carotid endarterectomy Head and neck surgery Orthopedic/Urology cases Low (<1%) Ambulatory surgery Endoscopic strategies Cataracts Breast surgery

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Case Presentation 80 yo male w/after late intense gallstone pancreatitis and cholecystitis presents for laparoscopic cholecystectomy. PMH: Ischemic cardiomyopathy, double chamber PM for AVB (2008), 2 vessel CABG (1980), 4 vessel CABG (1994), HTN, Hyperlipidemia, COPD. Useful limit: 4 METs, yet as of late turning out to be less dynamic 2 to SOB. Anomalous anxiety test (12/2009): inducible foremost apical and sub-par ischemia, EF: 40%.

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How might you continue? What might the cardiologist do? Phone in wiped out or drop the case. Take care of business and do the case. Call cardiology for further workup and to examine the PM. Rehash stress-test . Heart cath. Cross examination of the pacemaker. What is your perioperative arrangement? Nothing extravagant. Preinduction A-line, CVP, PAC, TEE, outside pacer-cushions. Preinduction A-line, forceful beta-barricade, ext. pacer-cushions.

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Perioperative Beta Blockade

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POISE Trial 8331 patients experiencing noncardiac surgery Metoprolol 100 mg or Placebo 2-4 hours preop and 6 hours postop Metoprolol 200 mg or Placebo 18 hours postop for 30 days Primary end point: composite of cardiovascular passing, MI, and nonfatal heart failure Fewer Metoprolol patients achieved the essential end point (5.8% versus 6.9%, p<0.04) or had a MI (4.2% versus 5.7%, p<0.0017). More Metoprolol patients passed on (p=0.03), had a stroke (p=0.0053), created huge hypotension (p<0.0001) and bradycardia (p<0.0001). The standard beginning day by day measurements of Metoprolol is 25-100 mg for HTN Poise Pts could get up to 400 mg on the main day

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DECREASE IV Trial 1066 transitional danger patients experiencing noncardiac surgery 4 bunches: Bisoprolol, Fluvastatin, both or nothing. Essential end point: composite of heart passing and nonfatal MI. Bisoprolol was begun 30 days before surgery and was titrated to a HR 50-70/min. It was proceeded until 30 days postop. The Bisoprolol bunch had a lower frequency of cardiovascular passing and nonfatal MI (2.1% versus 6.0%, p=0.002). Ischemic stroke rate was not essentially distinctive between the gatherings.

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Poldermans Study ( Decrease-bunch ) 770 middle danger patients experiencing vascular surgery Patients were haphazardly allocated to heart stress testing or no testing. All Pts got beta blockers titrated to a resting HR 60-65/min. Pts relegated to no testing had a comparable rate of cardiovascular occasions as those alloted to testing (1.8% versus 2.3%, p=ns). Pts with a HR<65/min had lower hazard than the rest (1.3% versus 5.2%, p=0.003). " Cardiac testing can securely be excluded in halfway hazard patients, gave that beta-blockers going for tight heart rate control are recommended ."

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Summary for Perioperative Beta Blocker Therapy Beta blockers ought to be proceeded in patients experiencing surgery who are accepting beta blockers for treatment of conditions with ACC/AHF Class I rule signs for the medications. (Class I) Several Class II proposals exist for Pts experiencing vascular or halfway hazard surgeries with different clinical danger components. Start certainly before an arranged strategy with cautious titration to accomplish satisfactory HR-control (60-80/min) while staying away from forthcoming bradycardia and hypotension is additionally proposed. Routine organization, especially higher altered measurement regimens started upon the arrival of surgery, can\'t be supported (POISE).

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Perioperative Management of Patients w/Coronary Artery Stents

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Why? Coronary Stents ≠ less perioperative issues and intricacies

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BMS and In-stent Restenosis

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A,B: 8/2005 LAD PCI with DES Stopped Plavix in 5/2006 C,D : 8/2006 MI 2 to LAD stent impediment Emergent inflatable dilatation DES Thrombosis E,F : platelets, fibrin and incendiary cells (neutrophils and eosinophils) in the thrombus

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Acute Perioperative Stent Thrombosis (BMS or DES)

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Cardiac Risk of Noncardiac Surgery after PCI with BMS 899 patients experiencing noncardiac surgery after BMS situation. 5.2% experienced MACEs (STEMI, NSTEMI, stent thromboses, rehash revascularizations and passings). The danger of MACEs after NCS was observed to be the most noteworthy inside 30 days of PCI w/BMS (10.5%), and least following 90 days (2.8%). Draining complexities were not connected with antiplatelet treatment.

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Cardiac Risk of Noncardiac Surgery after PCI with DES 520 patients experiencing noncardiac surgery after DES arrangement. 5.4% experienced MACEs (STEMI, NSTEMI, stent thromboses, rehash revascularizations and passings). The rate of MACEs did not change essentially with time after arrangement. Draining entanglements were few and were not connected with antiplatelet treatment.

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Cardiac Risk of NCS after PCI with BMS or DES

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Cruden study all inclusive review partner study. 1953 patients were treated with DES (n=570) or BMS (n=1383) and in this manner experienced noncardiac surgery. There were no distinctions in-healing facility mortality or MI between the 2 bunches, however perioperative demise and ischemic heart occasions happened all the more as often as possible when noncardiac surgery was performed inside 42 days of stent implantation. Mortality between 6 weeks – 1 year was still 4x higher than past 1 year.

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Elective Noncardiac Surgery and PCI Elective surgeries ought to be postponed to meet the above time-limits.

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The Perioperative Dilemma D/C-d antiplatelet drugs: hazard for perioperative stent thrombosis, MI and passing Continued plavix and headache medicine: potential for surgical dying

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Dual Antiplatelet Therapy Current ACC/AHA suggestions for the counteractive action of stent thrombosis after coronary stent implantation express that patients ought to be treated with clopidogrel 75 mg and ibuprofen 325 mg for one month after uncovered metal stent implantation, 3-6 months (in a perfect world 12 months) after DES implantation on the off chance that they are not at high hazard for dying. Be that as it may, these proposals depended on the antiplatelet regimen utilized as a part of trials to get FDA endorsement in okay patients with generally safe injuries. DES are presently being utilized high-chance lesions. There is no confirmation that warfarin, antithrombotics, or glycoprotein IIb/IIIa specialists lessen the danger of stent thrombosis after end of oral antiplatelet operators.

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Patients w/Cardiac Rhythm Management Devices

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Preoperative Evaluation Establish whether the patient has a CMRD. Characterize the kind of CMRD. Have the gadget investigated via cardiology. Decide reliance on pacing capacity of the CMRD. Figure out if EMI is liable to happen intraoperatively. Figure out if reconstructing pacing capacity to nonconcurrent mode or crippling rate responsive capacity is beneficial. Suspend antitachycardia capacities if present. Have transitory pacing and defibrillation hardware quickly accessible.

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Electromagnetic Interference Pacemaker/AICD reaction to EMI: Temporary or perpetual resetting to a reinforcement pacing mode. Transitory or changeless hindrance of pacemaker yield. Increment in pacing (rate-responsive PMs). AICD unseemly stun. Myocardial damage at the lead tip: inability to sense or catch. Sources: Electrocautery Radiofrequency removal MRI (contraindicated!) Radiation treatment ESWL ECT

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Electrocautery Assure that the electrosurgical accepting plate (otherwise known as "ground patch") is situated so that the present pathway does not go through or close to the CMRD framework. Stay away from the vicinity of the searing\'s electrical field to the beat generator or leads. Utilize short, discontinuous or unpredictable

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